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Digitized  by  tine  Internet  Archive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/textbookofobstetOOwebs 


A  TEXT-BOOK 


OF 


OBSTETRICS 


BY 

J.  CLARENCE  WEBSTER,  M.D.  (Edin.i,  F.R.C.P.E.,  F.R^.E. 

Professor  of  Obstetrics  and  G\  necology  in  Rush  Medical  College,  in  Affiliation  with 
the  University  of  Chicago  ;   Obstetrician  and  Gynecologist  to  the  Presby- 
terian Hospital  ;  Obstetrician  to  the  Chicago  Lying-in  Hospital  and 
Dispensary  ;  Consulting  Obstetrician,  Chicago  Maternity. 


383  31Uustrations; 
23  of  t\)cni  in  Colorsf 


PHILADELPHIA,  NEW  YORK,  LONDON 

W.    B.   SAUNDERS   &   COMPANY 
1903 


fKui  t^ 


Copyright,   igoj.   by   W.   B.   Saunders  &  Company 


Registered  at  Stationers'  Hall,  London.  England 


W  39 


ELECTROTYPED     BY  PRESS    OF 

WESTCOTT   &  THOMSON.    PHILADA.  W.    B.    SAUNDERS    &    COMPANY. 


TO 


FRANK    BILLINGS,  M.  D. 


Dean  of  the  Faculty  of  Medicine  in  Rush  Medical  College,  University  of  Chicago; 
President  of  the  American  Medical  Association 


IN   RECOGNITION   OF   HIS   DISTINGUISHED   SERVICES 

AS   A    PHYSICIAN   AND    AS   A   TOKEN 

OF    PERSONAL    ESTEEM 


XTbis  Dolume  is  DeMcatet) 


PREFACE. 


In  writing  this  volume  consideration  has  been  given  to  the 
needs  both  of  the  scientific  student  and  of  the  activ^e  practitioner. 

Particular  attention  is  directed  to  the  anatomic  changes  in 
pregnancy,  labor,  and  the  puerperium,  the  description  being 
largely  based  upon  studies  of  frozen  sections  published  in  recent 
years  by  the  author  and  other  workers.  Great  prominence,  also, 
is  given  to  embryologic,  physiologic,  and  pathologic  data  which 
are  of  importance  in  relation  to  obstetrics.  Several  of  these  have 
been  investigated  in  special  researches  by  the  author. 

The  practical  aspects  of  the  subject  are  presented  in  such  a 
manner  as  to  be  of  direct  assistance  to  the  clinical  worker.  Em- 
phasis is  given  to  methods  of  treatment  that  have  been  tested  by 
experience. 

Great  care  has  been  given  to  the  preparation  of  illustrations, 
many  of  which  have  never  appeared  in  a  text-book  of  obstetrics. 
In  their  selection  the  publishers  have  exercised  marked  generosity. 
Special  acknowledgement  is  due  to  Dr.  Robert  L.  Dickinson  for 
the  admirable  series  of  illustrations  taken  from  the  American 
Text-Book  of  Obstetrics,  the  drawings  for  which  were  originally 
made  for  that  work  under  Dr.  Dickinson's  supervision.  To 
my  associates,  Drs.  Holmes  and  Pierce,  my  thanks  are  due  for 
suggestions  and  assistance  in  the  reading  of  proofs  ;  to  Dr.  C. 
Wahrer  I  am  indebted  for  a  number  of  drawings  from  which 
illustrations  have  been  made. 

J.   CLARENCE  WEBSTER. 
loo  State  St.,  Chicago, 
October,  igoj. 


CONTENTS 


PART  I.-PREGNANCY. 

CHAPTER    I. 

PAGE 

Anatomy  and  Physiology  of  Pregnancy 17 

Conception  and  Generation 17 

Placentation 30 

Anatomy  of  the  Fetus 71 

Fetal  Physiology 80 

Anatomic  and  Physiologic  Changes  in  Maternal  System 90 

CHAPTER    II. 
Bacteriology  of  Vagina  in  Pregnancy 11 1 

CHAPTER   III. 

Diagnosis  of  Uterine  Pregnancy 113 

Signs  and  Symptoms 113 

Differential  Diagnosis  of  Pregnancy      125 

CHAPTER    IV 
Length  of  Gestation 129 

CHAPTER   V. 
Multiple  Pregnancy 133 

CHAPTER   VI. 

PSEUDOCYESIS I38 

CHAPTER    VII. 
Hygiene  and  Management  of  Pregnancy 138 


PART  II.— LABOR. 

CHAPTER    I. 

Clinical  Phenomena  of  Normal  Labor 145 

Comparative 145 

Classification  of  Labors 146 

Clinical  Phenomena 146 

First  Stage 147 

Second  Stage 151 

Third  Stage 155 

11 


12  CONTENTS. 

CHAPTER    II. 

PAGE 

Anatomy  and  Physiology  of  Normal  Labor 156 

First  and  Second  Stages ■  156 

Physiology 176 

Bony  Pelvis 184 

The  Passenger 199 

Presentations 202 

Mechanism  of  Labor 20S 

Third  Stage  of  Labor 215 

CHAPTER    III. 

Conduct  and  Management  of  Labor ,    .  224 

Preparations 224 

Management  of  First  Stage 227 

Management  of  Second  Stage 229 

Management  of  Third  Stage 235 

CHAPTER    IV. 

Asepsis  and  Antisepsis  in  Obstetrics 240 

CHAPTER   V. 

Anesthesia  in  Labor 245 


PART  in.— PUERPERIUM. 

CHAPTER    I. 
Anatomy  and  Physiology      248 

CHAPTER    II. 
Management  of  Puerperal  State     270 

CHAPTER    III. 
Newborn  Child  and  its  Management 273 


PART  IV -PATHOLOGY  OF  PREGNANCY. 

CHAPTER    I. 
Toxemia  of  Pregnancy 284 

CHAPTER   II. 
Affections  of  the  Nervous  System 286 

CHAPTER    III. 

Affections  of  Hemapoietic  and  Circulatory  Systems 289 


CONTENTS.  1 3 

CHAPTER    IV. 

I'AGK 

Affections  of  Respiratory  System 295 

CHAPTER   V. 
Affections  of  the  Osseous  System 297 

CHAPTER   VI. 
Affections  of  Alimentary  Tract  .    , 298 

CHAPTER   VII. 
Acute  Febrile  Diseases 303 

CHAPTER    VIII. 
Syphilis 307 

CHAPTER    IX. 
Affections  of  the  Urinary  System      .    - 310 

CHAPTER    X. 
Affections  of  the  Skin 319 

CHAPTER    XL 
Affections  of  the  Reproductive  System 319 

CHAPTER    XII. 

Diseases  of  the  Ovum 34° 

Amnion      34° 

Chorion      345 

Placenta 35° 

Umbilical  Cord 355 

CHAPTER    XIII. 
Premature  Expulsion  of  Uterine  Contents     357 

CHAPTER   XIV. 
Eclampsia 37° 

CHAPTER   XV. 
Ectopic  Pregnancy 397 


PART  V— PATHOLOGY  OF  LABOR. 

CHAPTER   L 
Anomalies  of  Expellant  Powers 423 

CHAPTER   II. 

Anomalies  of  the  Passages 428 

Soft  Parts 428 


14  CONTENTS. 

CHAPTER    III. 

PAGE 

Anomalies  of  the  Bony  Pelvis o    .    .  440 

CHAPTER    IV. 

Anomalies  of  the  Passenger 491 

Occipitoposterior  Presentations 492 

Face  Presentations        495 

Brow  Presentations 501 

Pelvic  Presentations 503 

Transverse  Presentations 5^5 

Prolapse  of  Arms  and  Legs 5^1 

Fetal  Anomalies  and  Diseases 5-- 

CHAPTER    V. 

Complex  Labor 539 

Placenta  Prrevia 539 

Hemorrhage  (Ablatio  Placentje) 556 

Hemorrhage  during  Third  Stage 565 

Postpartum  Hemorrhage      565 

Retained  Placenta 571 

Adherent  Placenta ,    .    .  574 

Rupture  of  L'terus 575 

Inversion  of  Uterus      588 

Heart  Disease  Complicating  Labor 559 


PART  VI.  -PATHOLOGY  OF  THE  PUERPERIUM. 

CHAPTER    I. 

Subinvolution,  Superinvolution,  etc 601 

Subinvolution        601 

Superinvolution 602 

Puerperal  Hemorrhage 603 

Chorio-epithelioma  Malignum 605 

frine      610 

Injuries  to  Nerves 612 

Puerperal  Insanity 613 

Disturbances  in  Breasts 614 

CHAPTER    II. 

Affections  of  Newborn  Infant 621 

Injuries  to  Head  during  Labor 621 

Fractures  of  Bones 623 

Injuries  of  Muscles 623 

Injuries  of  Nerves 624 

Injuries  of  Brain 625 

Asphyxia  Neonatorum 625 


CONTENl'S.  1 5 
CHAPTER    III. 

PAGK 

Puerperal  Infection 631 

Sapremia 636 

Mixed  Infection 637 

Pyemia 645 

Phlegmasia  Alba  Dolens 656 


PART  VII— OPERATIVE  OBSTETRICS. 

CHAr'TER    I. 

Artificial  Interruption  of  Pregnancy 659 

Abortion 659 

Premature  Labor 663 

CHAPTER    II. 
Version  or  Turning 669 

CHAPTER    III. 
The  Forceps  . 678 

CHAPTER    IV. 

Cesarean  Section '.7x0 

Porro's  Operation 718 

Gastro-elytrotomy 720 

CHAPTER    V. 
Symphysiotomy •    .    .    .    724 

CHAPTER   VI. 
Embryotomy 733 


INDEX 747 


PART   I. 

PREGNANCY 


CHAPTER    I. 
ANATOMY  AND  PHYSIOLOGY  OF  PREGNANCY. 

CONCEPTION  AND  GENERATION. 

Male  and  Female  Klemeuts. — A.  Ovum. — As  it  is  ready 
to  escape  from  the  ripe  Graafian  follicle,  the  ovum  measures  about 
0.2  mm.  and  has  the  following  structure : 

(a)  Deutoplasni  {Yolk  Protoplasm). — The  niain  part  of  the  ovum 
is  made  up  of  protoplasm,  containing  large  and  small  particles 
(nutritive)  with  strongly  refractile  powers. 

{b)  Clear  Protoplasm  {Egg  Plasm). — This  is  found  as  a  thin 
layer  surrounding  the  yolk  protoplasm,  and  also  as  another  imme- 
diately around  the  germinal  vesicle. 

{c)  Germinal  Vesicle  {^lYucleiis). — This  body  is  rounded,  and  has 
a  distinct  enveloping  nuclear  membrane  possessing  a  double  con- 
tour. Its  diameter  measures  about  T^yfj-,  on  the  average.  It  is 
situated  eccentrically. 

{d)  Germinal  Spot  {Nucleolus). — This  has  a  somewhat  yellow 
appearance,  and  according  to  Nagel  is  capable  of  ameboid  move- 
ments.    After  death  it  breaks  up  into  several  particles. 

{e)  ParaniLcleolus. — One  or  more  may  be  seen.  They  are  appar- 
ently thickenings  in  the  protoplasmic  reticulum  of  the  nucleus. 

Surrounding  the  ovum  is  a  very  narrow  slit,  the  perivitelline 
space.  External  to  this  is  a  thin,  striated,  structureless  membrane, 
the  zona  pellucida,  measuring  about  14/^  in  thickness.  This  is 
probably  derived  from  the  surrounding  cells  of  the  discus  pro- 
ligerus. 

The  cells  of  the  two  inner  layers  of  the  discus  are  arranged 
with  their  long  axes  radial  to  the  ovum.  The  innermost  row  pre- 
sents longitudinal  striae,  which  are  apparently  continuous  with 
those  in  the  zona  pellucida ;  this  layer  has  been  termed  by 
Bischoff  the  corona  radiata.  The  outer  cells  of  the  discus  are  more 
rounded,  and  consist  of  a  finely  granular  protoplasm  with  large 
nuclei.  The  stalk  of  the  discus  consists  of  cells  similar  to  those 
of  the  stratiim  granulosum.  The  latter  is  composed  of  two  or 
2  17 


I  8  AJV^  rOM Y  AND   PH YSIOL OGY  OF  PRE GNANC Y. 

more  layers  of  low  cylindric  cells,  forming  the  inner  wall  of  the 
follicle.  These  are  probably  derived  from  the  original  germinal 
epitheHum,  though  some  hold  that  they  are  mesodermic  in  origin. 
The  liquor  folliculi  is  a  clear,  slightly  yellow,  glairy  fluid,  rich  in 
paralbumin.  External  to  the  stratum  granulosum  is  the  tJicca 
folliculi,  derived  from  the  connective-tissue  stroma  of  the  ovary. 
It  consists  of  an  outer  layer,  the  tunica  externa  ox  fibrosa,  made  up 
of  compressed  connective  tissue,  and  an  inner,  the  timica  interna 
or  propria,  more  cellular  than  the  outer  and  rich  in  capillaries. 

The  ripe  Graafian  follicle  forms  a  bulging  on  the  surface  of  the 
ovary.  Rupture  takes  place  at  the  most  prominent  part,  the  thin 
covering  of  ovarian  tissue  being  somewhat  degenerated.  The  cause 
of  rupture  is  not  yet  definitely  known.  As  the  ovum  escapes,  sur- 
rounded by  the  zona  pellucida,  some  cells  of  the  discus  are  prob- 
ably carried  with  it.  They  gradually  disappear,  and  the  zona  is 
also  lost  in  cases  where  conception  occurs,  before  the  ovum  is 
well  embedded  in   the   uterine  mucosa. 

Formation  of  the  Corpus  Luteum. — After  escape  of  the  ovum, 
the  Graafian  follicle  is  filled  with  blood  and  cells  of  the  stratum 
granulosum.  The  rapidly  thickened  inner  layer  of  the  wall  of 
the  follicle  becomes  arranged  in  a  wavy  manner,  so  that  the  cen- 
tral cavity  becomes  an  irregular  stellated  slit.  It  is  known  as 
the  yellow  band,  li'om  the  presence  of  numerous  yellow  particles 
(lutein  cells)  in  its  substance.  The  blood  is  gradually  absorbed 
so  that  the  central  space  is  almost  obliterated.  The  lutein  cells 
of  the  yellow  band  disappear,  and  the  latter  assumes  a  colloid 
appearance,  known  as  the  corpus  albicans,  in  the  center  of  which 
a  few  blood-crystals  may  be  found  ;  its  size  slowly  diminishes. 
Throughout  these  changes  blood-vessels  and  connective-tissue 
elements  extend  from  the  periphery  toward  the  center  of  the 
follicle  ;  as  shrinkage  of  the  corpus  occurs,  sclerosis  and  hyaline 
degeneration  take  place  in  the  vessel-walls. 

The  terms  "  true  corpus  luteum  "  and  "  false  corpus  luteum  " 
should  not  be  used.  The  former  is  applied  to  the  condition  in 
pregnancy,  the  latter  to  that  found  in  the  non-pregnant  state. 
There  is  practically  no  difference  save  as  regards  duration. 
When  pregnancy  occurs,  the  corpjis  hitcuui  becomes  reduced  in 
size  only  in  the  course  of  several  months  ;  when  pregnancy  does 
not  occur,  in  a  few  weeks'  time.  Clark  points  out  that  in  the 
former  case  the  vessels  are  much  more  congested  than  in  the 
latter. 

Fate  of  the  Ripened  Ova. — Some  are  disintegrated  and  ab- 
sorbed in  the  peritoneal  cavity,  others  in  the  tube  and  uterus  ;  pos- 
sibly some  reach  the  vagina  ;  others  become  fertilized.  It  has  been 
shown  that  there  is  a  line  of  movement  on  the  moist  surface  of 
the  pelvic  peritoneum  in  each  half  of  the  pelvis,  the  direction 
being  toward  the  fimbriated  end  of  the  tube,  the  current  being 


CONCEPTION  AND    GENERATION. 


19 


probably  due  to  the  movements  of  the  cilia  on  the  fimbriae.  It  is 
due  to  this,  probably,  that  the  shed  ova  move  toward  the  tube. 
It  is  not  known  how  long  a  time  is  taken  in  the  passage  of  the 
ovum  to  the  tube  or  along  the  tube  to  the  uterus.  In  several 
animals  the  transit  has  been  observed  to  last  three  to  five  days ; 
in  a  bitch,  eight  days.  As  the  fertilized  ovum  passes  along  the 
tube  it  probably  absorbs  some  fluid  from  the  lumen. 

Maturation  or  Ripening  of  the  Ovum. — Each  ripe  ovum  is 
believed  to  undergo  changes  preparatory  to  fertilization,  whether 
the  latter  occurs  or  not.  As  studied  in  some  of  the  lower  animals 
they  are  as  follows :  The  germinal  vesicle  moves  toward  the  periph- 
ery of  the  ovum,  where  a  small  portion  splits  off,  and,  surrounded 
by  a  little  protoplasm,  moves  outward  until  it  lies  on  the  surface 
of  the  ovum  under  the  zona  radiata.     This  extended  portion  is 


Fig.  I. — Formation  of  polar  bodies  in  ova  of  Asterias  glacialis  (Hertwig):  ps. 
Polar  spindle;  pb' ,  first  polar  body;  pb" ,  second  polar  body;  «,  nucleus  returning  to 
condition  of  rest. 


termed  the  first  polar  body  or  globule.  The  germinal  vesicle  then 
moves  toward  the  center  of  the  ovum  and  advances  toward  the 
periphery  at  another  point,  a  portion  again  being  extruded,  known 
as  the  second  polar  body.  The  rest  of  the  vesicle  then  moves 
toward  the  center  of  the  ovum,  being  thereafter  known  as  the 
female  pronucleus.     The  polar  bodies  soon  after  disappear. 

B.  Male  Element. — The  spermatozoa,  essential  to  the  fertili- 
zation of  the  ovum,  are  contained  in  the  semen  of  the  male,  a 
viscid,  opalescent  fluid  made  up  of  secretions  from  the  testicles, 
prostate,  and  Cowper's  glands,  and  containing  mainly  spermatin,  an 
albuminous  material,  and  several  inorganic  salts.  Under  the  micro- 
scope, besides  the  spermatozoa,  are  seen  epithelial  cells  from  the 
genital  and  urinary  canals,  and  small  highly  refractile  particles — 
seminal  globules,  which  are  probably  derived  from  the  nuclei  of 
broken-down  cells  of  the  seminiferous  tubules.     Each  spermato- 


20 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


zoon   consists  of  an   ovoid  head,  the   small   end  being  anterior, 

measuring  about   g-jjVn"  i^''-  lo^g-  ^  ^^i^  Too"  ^^  4W  ^'''-  ^^  length, 
and  an  intermediate  portion  shorter  than  the  head.     When  active 

the  spermatozoa  are  propelled  in  a 
spiral  course  by  lashing  movements 
of  the  tail.  If  the  semen  be  kept 
at  body  temperature,  they  continue 
active  for  hours.  It  is  by  their 
own  motile  power  that  they  ad- 
vance upward  along  the  female 
genital  tract.  Here  their  vitality 
may  be  little  altered  for  several 
da}'s.  They  have  been  found  in 
the  uterus  a  week  after  coitus. 
Diihrssen  reports  a  case  in  which 
living  spermatozoa  were  found  in 
one  Fallopian  tube  removed  from 
a  woman  who  had  been  in  the  hos- 
pital nine  days,  and  who  stated  that 
her  last  coitus  had  taken  place  three 
and  a  half  weeks  previous  to  opera- 
tion. The  time  for  the  passage  of 
the  spermatozoa  from  the  vagina  to  the  fundus  uteri  or  to  the 
pavilion  of  the  tube  is  not  known.     It  probably  varies  under  dif- 


FlG.  2. — Egg  of  an  echinoderm. 
At  one  portion  of  the  surface  two 
spermatozoa  are  seen.  Within  the 
ovum  are  seen  the  female  pronucleus 
and  the  male  pronucleus.  Radiating 
lines  extend  from  the  latter  as  it  ap- 
proaches the  former  (Flem.ming). 


Fig.  3. — Ovum  of  a  bitch  fourteen  and  a  half  hours  after  copulation  (Kollmann). 
Several  spermatozoa  are  in  the  substance  of  the  zona  pellucida  (a).  Two  polar  bodies 
{b)  are  seen  under  the  zona  pellucida,  surrounded  with  clear  albuminous  fluid  (r)  ;  in 
the  latter  two  spermatozoa  are  penetrating.  The  large  rounded  central  portion  of  the 
ovum  ((/)  contains  the  yolk  particles. 


ferent  conditions.    Henle  has  calculated  the  rate  at  about  2.7  mm. 
per  minute. 

Place  of  Fertilisation. — The  ovum  may  meet  the  spermatozoa 


CONCEPTION  AND    GENERATION.  21 

anywhere  in  its  passage  from  the  ovary  to  the  uterine  cavity. 
Some  believe  that  the  latter  is  the  most  frequent  place  of  union, 
though  most  authorities  think  that  it  is  probably  the  outer  end  of 
the  Fallopian  tube,  as  this  appears  to  be  a  favorite  resting-place 
of  the  spermatozoa. 

Nature  of  Fertilization. — This  is  unknown  in  the  human  female. 
It  has  been  observed  in  several  invertebrates — /.  £\,  echinoderms, 
moUusca,  ascarides,  etc.  Among  the  higher  vertebrata  various 
stages  have  been  observed  in  different  forms — /.  c.,  dog,  mouse, 
rabbit,  etc. 

The  spermatozoa  penetrate  the  zona  pellucida,  though  in  what 
numbers  is  not  known  in  the  human  subject.  Kollmann  has 
counted  as  many  as  sixty  attempting  penetration  in  the  case  of  a 
bitch.  In  some  of  the  lower  animals  there  is  an  opening  in  the 
zona,  known  as  the  micropyle,  through  which  the  spermatozoon 


Fig.  4. — Ovum  of  mouse,  showing  polar  body  (a)  under  the  zona  pellucida  (c),  and 
below  it  the  rest  of  the  nuclear  spindle.  At  another  point  {b)  there  is  an  elevation  near 
the  surface,  into  which  a  spermatozoon  {d)  has  penetrated  (Sobotta). 

enters.  This  is  wanting  in  the  human  ovum.  Though  many  may 
attempt  an  entrance,  it  is  probable  that  only  one  performs  the 
essential  act  of  fertilization — /.  e.,  blends  with  the  female  pro- 
nucleus. At  the  point  where  this  one  is  about  to  enter,  the  proto- 
plasm of  the  ovum  forms  a  swelling  under  the  zona,  known  as  the 
receptive  prominence.  Through  this  the  spermatozoon  bores  its 
way,  losing  its  tail,  the  head  becoming  the  male  pronucleus. 
Around  it  radial  lines  appear  in  the  yolk  protoplasm.  The  male 
and  female  pronuclei  now  move  toward  one  another,  and  blending 
of  the  two  occurs,  followed  by  a  short  period  in  which  they  can- 
not be  recognized.  Soon  they  reappear  as  a  single  mass,  hence- 
forth known  as  the  segmentation  or  cleavage  nucleus.  Fertilization 
is  now  complete. 

Segmentation. — The  early  changes  in  the  fertilized  ovum 
have  not  been  studied  in  the  human  subject,  but  they  have  been 
carefully  investigated  in  several  of  the  higher  vertebrates  and  in 


22 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


some  invertebrates.  In  most  cases  observed  the  segmentation 
nucleus  undergoes  changes  of  a  karyokinetic  nature,  dividing  into 
two  halves,  which  diverge  to  opposite  ends  of  the  ovum,  radial 
lines  appearing  in  the  protoplasm  around  them.  The  ovum  is 
then  divided  into  two  by  an  equatorial  groove  that  extends 
inward  from  the  surface.  Each  of  the  cells  thus  formed  divides 
again  into  two,  and  so  on  until  a  mass  of  cells  or  blastomeres  is 
formed,  known  as  the  mulberry  mass,  muriform  body,  or  morula. 
This  method  of  segmentation,  in  which  the  whole  ovum  is  divided, 
is  termed  holoblastic.  There  are  two  varieties  of  holoblastic  ova- — 
viz.,  those  in  which  there  is  total  equal  cleavage,  and  those  in  which 
there  is  total  unequal  cleavage.  The  human  ovum  undoubtedly 
belongs  to  the  former  of  these.    (In  contradistinction  to  holoblas- 


FlG.  5. — a,  The  beginning  of  seg- 
mentation in  the  mouse's  ovum.  One 
portion  is  slightly  larger  than  the 
other,  though  the  nuclei  appear 
alike.  In  the  next  stage  {b)  the 
nucleus  of  the  smaller  portion  un- 
dergoes division  before  that  in  the 
other  half  (Sobotta). 


Fig.  6. — First  stage  of  segmentation  in 
the  ovum  of  a  field-mouse  (Van  Beneden). 
One  half  {a)  is  slightly  smaller  than  the 
other  {b).  In  the  center  of  each  is  seen 
the  nucleus,  the  dark  bodies  being  yolk 
particles  ;  c,  zona  pellucida  ;  d,  polar  body. 


tic  segmentation  is  that  termed  meroblastic,  in  which  division  only 
of  part  of  the  ovum  occurs.) 

There  next  appears  in  the  interior  of  the  morula  a  fissure, 
known  as  the  cleavage  or  segmentation  cavity.  This  increases 
until  a  considerable  space  is  formed  containing  an  albuminous 
fluid.  This  period  of  development  is  termed  the  blastula  stage, 
the  ovum  being  known  as  the  blastodermic  vesicle.  As  observed 
in  the  dog  and  other  mammals,  the  outer  wall  consists  of  a  single 
layer  of  cells  (Rauber's)  made  up  of  clear  protoplasm.  Internal 
to  this  is  a  heap  of  dark  granular  cells,  attached  at  one  part  and 
projecting  into  the  central  cavity.  The  whole  vesicle  is  still  within 
the  zona  pellucida  (which  has  been  sometimes  termed  the  procJio- 
rion).  As  increase  in  size  takes  place  the  outer  layer  gradually 
thins,  the  cells  becoming  difficult  to  recognize. 


PLATE  I. 


Outer  cell.  Outer  eelh 


I,  2,  3,  Diagrams  illustrating  the  segmentation  of  the  mammalian  ovum  (Allen 
Thomson,  after  van  Beneden).  4,  Diagram  illustrating  the  relation  of  the  primary 
layers  of  the  blastoderm,  the  segmentation-cavity  of  this  stage  corresponding  with 
the  archentcrtjn  (jf  amphioxus  (Bonnet). 


CONCEPTION  AND    GENERATION. 


23 


The  inner  cell-mass  becomes  differentiated  into  an  outer  and 
an  inner  layer,  the  early  epiblast  and  hypoblast.  The  former 
grows  rapidly,  extending  all  around  the  vesicle  under  the  remains 
of  Rauber's  cells  ;  possibly  the  remains  of  the  latter  blend  with 
the  epiblastic  layer.  The  hypoblast  extends  more  slowly  as  an 
inner  Uning  to  the  epiblastic  layer. 
This  period  of  development  is 
known  as  the  bilaminar  stage  of 
the  blastodermic  vesicle  (corre- 
sponding to  the  gastrula  stage  in 
many  of  the  lower  forms  of  animal 
life). 

Bttibryonal  Area.  —  After 
the  differentiation  of  the  epiblast 
and  hypoblast  there  occurs  a  thick- 
ening of  these  layers  at  the  point 
where  the  original  inner  cell-mass 
touched  the  outer.  This  thicken- 
ing, as  seen  on  surface  view  in  the 
rabbit's  ovum,  is  at  first  rounded, 
then  oval,  and  afterward  pear- 
shaped.  This  is  the  embryonal 
area,  and  it  is  here  that  the  body  of  the  embryo  is  developed, 
the  broad  portion  being  the  site  of  its  head.  At  the  small  or 
caudal  extremity  thei'e  is  a  transverse  thickening  called  the  termi- 
nal ridge.  Very  soon  a  longitudinal  mark  appears  in  the  long  axis 
of  the  embryonal  area,  extending  over  about  two-thirds  of  its 
length  and  known  as  the  primitive  streak.  This  appearance  is 
produced  by  a  linear  proliferation  of  cells  of  the  epiblast.  (Mor- 
phologically this  streak  corresponds  to  the  closed  and  drawn-out 


Fig.  7. — Segmentation  stage  in 
which  the  ovum  of  the  field-mouse 
is  divided  into  four  cells  (Van  Bene- 
den). 


WiMMM^M^ 


Fig.  8. — Section  across  the  primitive  streak  of  rabbit  embryo  (Kolliker) :  ec,  Ecto- 
derm ;  ax.  ec,  axial  ectoderm  undergoing  proliferation,  as  shown  by  karyokinetic  figures 
(k)  ;  ent,  entoderm  ;  m,  mesoderm. 


blastospore,  the  passage  which  in  the  gastrula  stage  of  lower 
animals  communicated  with  the  cavity  of  the  vesicle  or  archen- 
teron.  In  the  human  embryonic  area  the  transverse  ridge  is 
believed  to  indicate  the  point  corresponding  to  the  blastospore 
of  lower  forms.)  On  the  surface  of  the  streak  a  long  shallow 
groove  appears,  known  as  the  primitive  groove.    The  anterior  end 


24 


AXATOJl/V  AND  PHYSIOLOGY  OF  PREGNANCY. 


^ Htad-pr 


Xode  of  Hensen. 
Neurenteric  canal. 


—   — Prunitive  streak. 


Fig.  9. — Embryonic  area  of  rabbit  embryo  (Van  Beneden).     Primitive  streal<  begin- 
ning in  cell  proliferation,  known  as  the  "  node  of  Hensen." 

of  the  streak  is  marked  by  a  kind  of  knob  formed  by  an  accumu- 
lation of  cells  under  the  surface,  known  as  Hensen's  node.    Soon 


Medullary 
plates. 


Primitive 
streak  and 
groove. 


Fig.  10. — Surface  view  of  area  pellucida  of  an  eighteen-hour  chick  embryo  (Balfour) 


another  linear  mark  develops  anterior  to  the  streak  and  in  line 
with  it,  termed  the  head-process  of  the  primitive  streak. 

Trilaminar  Blastoderm. — A  third  layer  of  cells  now  de- 


CONCEPTION  AND    GENERATION. 


25 


velops,  the  mesoblast.  Its  origin  in  the  higher  vertebrates  is 
not  definitely  known.  In  all  probability  it  is  formed  both  from 
the  epiblast  and  hypoblast  layers,  appearing  first  under  the 
anterior  end  of  the  primitive  streak.  After  its  differentiation  as 
a  distinct  layer  its  future  growth  takes  place  by  the  independent 
proliferation  of  its  own  cells.  It  spreads  laterally  and  posteriorly, 
and  later,  from  the  anterior  end  of  the  central  mesoblastic  layer, 
two  expansions  grow  forward,  curving  so  that  their  tips  meet  in 
the  middle  line,  enclosing  a  crescentic  space  known  as  the  pro- 
amnion. Soon  after  the  appearance  of  the  mesoblast  the  med- 
ullary groove  appears  in  front  of  the  primitive  streak.  It  is 
formed  by  the  development  of  the  medullary  folds,  two  layers  of 


•■■•■lillUP*— ' 


Fig.  II. — Diagrammatic  surface  view  of  rabbit's  ovum  of  two  hundred  and  five 
hours  (after  Tourneux).  The  darkly  shaded  area  indicates  the  extent  of  the  mesoderm  : 
a,  Peripheral  limit  of  area  opaca;  b,  of  area  pellucida;  c,  of  parietal  zone;  d,  of  stem 
zone;  f,  Hensen's  node;  g,  proamnion. 


epiblast  that  begin  in  front  of  the  head  process  and  extend 
backward.  These  folds  curl  inward  until  they  coalesce  from 
before  backward,  forming  the  neural  tube  or  canal,  the  original 
primitive  streak  being  gradually  enclosed  in  the  canal. 

From  this  tube  the  whole  future  nervous  system  is  developed. 
While  the  neural  canal  is  developing  a  solid  column  of  cells 
forms  under  it,  derived  from  the  hypoblast.  This  is  the  noto- 
chord  or  chorda  dorsalis,  the  axis  around  which  the  permanent 
spinal  column  is  developed.  It  largely  disappears  afterward, 
being  represented  in  postnatal  life  only  by  the  pulp  in  the  center 
of  the  intervertebral  disks. 

Extension  of  the  Mesoblast. — The  early  mesoblast  grad- 


26 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


ually  arranges  itself  in  two  paraxial  columns,  situated  one  on 
either  side  of  the  middle  line,  and  in  two  lateral  plates  extending 
outward  from  these.  Each  of  the  latter  divides  into  two  lamellae  : 
the  outer  or  somatic  mesoblast  extends  under  the  ectodermic 
layer,  forming  with  it  the  somatopleure ;  the  inner  or  splanchnic 
mesoblast  extends  over  the  hypoblastic  layer,  forming  with  it  the 
splanchnopleure.  The  space  between  the  somatopleure  and  the 
splanchnopleure  is  the  celom,  body  cavity,  or  pleuroperitoneal 
cavity.  The  mesodermic  cells  lining  this  cavity  become  flattened 
and  endothelial  in  nature,  being  often  termed  the  mesothelium. 

Mesoblastic  Somites. — Early  after  the  appearance  of  the 
paraxial  mesoblastic  columns  transverse  division  occurs  in  them. 


Fig.  12. — Reconstruction  of  an  early  stage  in  development  (Graf  Spee):  a.  Yolk- 
sac;  b,  amnion  opened  up;  c,  m.eduUary  groove;  d,  neurenteric  canal;  e,  primitive 
groove;  f,  abdominal  stalk,  below  which  is  a  portion  of  the  chorion. 

being  first  marked  at  the  cephalic  end,  and  afterward  appearing  in 
the  rest  of  their  extent.  The  position  of  these  divisions  is 
indicated  by  transverse  parallel  lines  on  the  surface  of  the 
embr}'onal  area.  The  segments  thus  formed  are  known  as  the 
somites,  the  anterior  one  being  formed  before  the  medullary  folds 
have  blended  to  form  the  neural  canal.  This  segmentation 
process  is  of  interest  in  relation  to  the  future  development  of  the 
bony  and  muscular  structure  of  the  body  and  of  the  genito- 
urinar}'  apparatus. 

Delimitation  of  the  Bmbryo. — During  the  progress  of 
some  of  the  changes  just  described,  grooves  appear  on  the  surface 
of  the  embryonic  area,  one  anteriorly,  one  posteriorly,  and  one 


CONCEPTION  AND    GENERATION. 


27 


on  each  side.  These  grooves  increase  in  length  and  meet  to 
form  one  continuous  furrow  that  runs  around  the  embryonic 
area.  At  first  the  groove  is  a  mere  depression  in  the  somato- 
pleure.  As  it  gradually  deepens  the  splanchnopleure  becomes 
depressed  under  it.  This  infolding  around  the  embryonic  area, 
toward  its  inferior  surface,  causes  a  gradual  constriction  of  the 
archenteron,  dividing  it  unequally  into  two  portions.  The  smaller 
of  these,  superficially  placed,  becomes  the  intestinal  canal  of  the 
embryo,  while  the  larger,  deeper  part  remains  as  the  yolk-sac  or 
umbilical  vesicle.  The  constricted  passage  joining  the  two 
becomes  the  vitelline  duct. 

It  is  then  evident  that  that  portion  of  the  somatopleure  that 
forms  the  inner  wall  of  the  groove  becomes  the  lateral  and  ventral 
body-wall  of  the  embryo,  whose  delimitation  from  the  embryonic 


mMm. 


Fig.  13. 


-Diagrammatic  sections  representing  growth  and  arrangement  of  the  amnion 
in  the  earliest  stages  of  the  human  embryo  (His). 


area  is  thereby  brought  about.  Pari  pass2i  with  these  changes 
the  somatopleure  forming  the  outer  wall  of  the  groove  becomes 
elevated  in  a  fold  known  as  the  fold  of  the  amnion.  This  is  often 
described  in  four  parts — the  head  fold,  the  tail  fold,  and  the  lateral 
folds  ;  in  the  human  ovum,  however,  there  is  no  tail  fold.  These 
rise  over  the  head  and  back  of  the  embryo  as  the  latter  sinks 
inward  upon  the  umbilical  vesicle,  the  head  fold  growing  toward 
the  caudal  end.  They  blend  from  before  backward  so  as  to  form 
a  complete  cavity ;  and  after  fusing,  the  two  layers  of  the 
amniotic  fold  separate,  the  inner,  forming  the  true  amnion,  having 
epiblast  on  its  inner  surface  and  mesoblast  on  its  outer;  the  outer 
layer,  often  termed  the  serosa  or  false  amnion,  is  continuous  with 
the  original  somatopleure,  and  with  it  forms  the  early  or  primitive 
chorionic  membrane.     It  is  composed  of  an  outer  layer  of  epiblast 


28 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


and  an  inner  one  of  mesoblast.  This  chorionic  membrane  is  not 
entirely  cut  off  from  the  embryo,  but  is  connected  with  it  at  its 
caudal  end  by  a  process  termed  the  abdominal  stalk  {baucJisticl), 
which  also  serves  to  join  it  to  the  true  amnion,  the  deepening  of 
the  early  surface  groove  having  resulted  in  the  delimitation  of  the 
embryo,  so  that  it  is  left  attached  to  the  surrounding  tissues  only 
at  its  posterior  end.  The  amnion  at  first  envelops  only  the  back 
and  sides  of  the  embryo.  Gradually  it  extends  around  the  latter 
until  it  surrounds  it  as  far  as  the  circumference  of  the  abdominal 
stalk.     As  development  continues,  the  amniotic  cavity  enlarges 


^4    ft 


Fig.  14. — Mesial  section  through  an  early  human  ovum  (Graf  Spec)  :  a,  .A.bdominal 
stalk;  iJ,  amnion  ;  c,  yolk-sac;  (/.hypoblast;  e,  mesoblast;  f,  vessels  on  wall  of  yolk- 
sac  ;  g,  primitive  streak;  //,  allantois;  /,  medullary  plate  ;  y,  early  heart ;  ,^,  mesoblast 
of  chorion  ;  /,  early  villi ;   m,  chorionic  mesoblast  extending  outward  into  villi. 


until  it  occupies  the  entire  space  within  the  chorion,  with  the  inner 
surface  of  which  it  becomes  connected. 

Importance  of  the  Abdominal  Stalk. — This  structure  is 
the  forerunner  of  the  umbilical  cord,  connecting  the  fetus  and  pla- 
centa. It  is  the  pathway  along  which  the  vessels  of  the  embryo 
extend  toward  the  future  chorionic  villi.  The  amnion  does  not  form 
its  outer  covering,  but  blends  with  it  at  the  end  farthest  from  the 
embiyo.  Its  covering  of  epiblast  is  the  same  as  that  of  the  skin 
of  the  early  embiyo.  Within  the  stalk  is  found  at  first  the  yolk- 
sac  and  duct,  a  continuation  of  the  celom,  and  the  allantois  about 
to  be  described. 


CONCEPTION  AND    GENERA  TION. 


29 


The  stalk,  at  first  situated  at  the  posterior  end  of  the  embryo, 
gradually  changes  its  position,  becoming  more  centrally  placed  on 
the  ventral  surface,  owing  to  the  growth  of  the  tail  end  of  the 
embryo. 


-/ 


Fig.  15. — Early  human  ovum  (Graf  Spee).  A  portion  of  the  chorionic  membrane 
with  the  anlage  of  the  embryo  is  seen  on  its  inner  surface  :  a.  Amnion  surrounding 
anlage  of  embryo;  b,  yoll<-sac;  c,  blood-islands  in  the  yolk-sac;  d,  abdominal  stalk 
{bauchstiel)  connecting  embryo  and  chorion  ;  e,  chorionic  membrane  (serosa) ;  /",  early 
villi  of  the  chorion  ;  g,  outer  or  epiblast  layer  of  chorion ;  h,  inner  or  niesoblast  layer 
of  chorion. 

Allantois. — In  the  human  female  there  is  no  such  devel- 
opment of  allantois  as  is  found  in  some  of  the  lower  verte- 
brates. In  the  latter  it  is  an  outgrowth  of  the  lower  guf,  which 
extends  into  the  extra-embryonic  celom  and  spreads  out  under 
the  false  amnion  or  chorion,  performing  an  important  part  in  the 
formation  of  the  placenta.     In  the  human  ovum  it  arises  from  the 


Fig.  16. — Section  of  early  human  ovum  (Graf  Spee)  :  a,  Anlage  of  embryo  ;  /^  yolk- 
sac  ;  c,  amnion  ;  d,  abdominal  stalk  ;  e,  chorionic  membrane  ;/",  epiblast  layer  of  chorion  ; 
g,  mesoblast  layer  of  chorion. 

lower  end  of  the  intestine  and  passes  into  the  abdominal  stalk, 
but  does  not  extend  outward  and  spread  under  the  chorion. 
Along  its  side  the  umbilical  arteries  extend  into  the  stalk  on  their 
way  to  the  chorion.     The  allantois  is   mainly  concerned  in   the 


30  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 

formation  of  the  bladder.  It  does  not  appear  to  be  essential  to 
the  vascularization  of  the  chorion,  for  occasionally  complete 
absence  of  the  bladder  may  be  found  along  with  vascularization 
of  the  chorion  by  vessels  derived  probably  from  the  omphalo- 
mesenteric branches  of  the  aorta  of  the  embryo. 

PLACENTATION. 

Influence  of  Fertilisation  on  the  Uterine  Mucosa. — 

As  the  result  of  the  fertilization  of  the  ovum  a  genetic  reaction 
takes  place,  leading  to  changes  in  the  mucosa  of  the  body  of  the 
uterus.  That  the  presence  of  the  ovum  within  the  uterine  cavity 
is  not  necessary  to  initiate  this  reaction  is  evident  from  what 
occurs  in  ectopic  gestation,  in  which  the  genetic  reaction  in  the 
uterus  is  identical  with  that  which  is  found  in  the  early  stages  of 
uterine  pregnancy.  In  the  latter  condition,  therefore,  if  the  ovum 
be  fertilized  in  the  tube,  the  reaction  may  be  noted  before  the 
ovum  reaches  the  uterine  cavity.  The  mucosa  of  the  body, 
altered  as  the  result  of  the  genetic  reaction,  is  known  as  the 
decidua  vera. 

Decidua  Vera. — Before  studying  the  transformed  mucosa  it 
is  well  to  recapitulate  the  following  points  regarding  the  normal 
mucosa  of  the  uterine  body  as  it  is  found  in  nulliparae  : 

1.  Its  thickness  is  not  uniform,  but  varies  considerably. 

2.  The  superficial  epithelium  shows  variations  in  the  height, 
thickness,  and  shape  of  the  cells,  and  in  the  position  of  their 
nuclei. 

3.  The  same  may  be  said  of  the  epithelial  cells  lining  the 
glands ;  in  general  these  are  larger  than  the  surface  cells. 

4.  The  interglandular  connective  tissue  is  mainly  embryonal 
in  nature,  consisting  of  a  nucleated  protoplasmic  reticulum  ;  here 
and  there  are  found  all  stages  of  transformation  to  the  more 
advanced  spindle  cells. 

5.  The  connective-tissue  cells  nearest  the  surface  of  the  mucosa 
are  arranged  for  the  most  part  parallel  to  it.  A  special  layer  of 
these,  arranged  as  a  basement  membrane  under  the  surface 
epithelium,  can  be  distinctly  seen  in  many  places.  Outside  the 
epithelium  of  the  glands  the  basement  membrane  is  also  found. 

6.  In  the  superficial  portions  of  the  mucosa  the  capillary 
junctions  of  the  arteries  and  veins  are  the  only  vessels  usually 
found. 

7.  The  line  of  junction  of  the  mucosa  and  the  muscular  part 
of  the  wall  is  an  irregular  one.  There  is  no  special  muscularis 
mucosae. 

The  changes  that  take  place  in  the  formation  of  the  decidua 
vera  are  as  follows  :  The  mucosa  becomes  swollen  and  divided  by 
furrows  into  a  series   of  flattened  or  rounded  areas  of  different 


PLACENTA  TION. 


31 


sizes.  The  earliest  specimen  of  which  there  is  record  is  that 
described  by  Peters,  of  Vienna,  in  which  pregnancy  was  not  ad- 
vanced more  than  five  or  six  days.  The  tissues  were  edematous 
and  the  vessels  congested.  The  surface  epithelium  was  intact,  the 
cells  being  slightly  lower  than  in  the  non-pregnant  state.  Gland- 
ular hypertrophy  had  commenced,  the  cells  being  in  places  some- 
what separated  from  one  another  and  from  the  gland-wall.  Near 
the  ovum  there  was  slight  enlargement  of  some  of  the  connec- 
tive-tissue  cells,  and   extravasated    blood-corpuscles  were   found 


Fig.  17. — Pregnant  uterus  in  second  half  of  first  week.  The  cavity  has  been  laid 
open,  showing  the  altered  condition  of  the  mucosa  (H.  Peters)  :  Ei  marks  the  site  at 
which  the  ovum  is  embedded. 


in  different  places.  After  the  first  week  more  distinct  changes 
are  found  ;  the  lining  epithelium  becomes  more  columnar,  in  parts 
appearing  more  cubical  or  even  flattened,  the  nuclei  becoming 
rounded  or  flattened  somewhat  parallel  to  the  surface  of  the 
decidua,  the  cilia  gradually  disappearing.  Here  and  there  strips 
of  epithelium  or  individual  cells  may  become  detached  from  the 
surface.  In  some  parts  the  cell  substance  disappears,  the  nucleus 
alone  being  left,  and  in  others  the  nucleus  may  be  found  in  the 
first  stages  of  degeneration.  The  probable  cause  of  degeneration 
in  the  covering  epithelium  is  the  rapid  growth  of  the  intergland- 


32 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


ular  cellular  tissue,  causing  stretching,  flattening,  and  separation 
of  the  superjacent  epithelium,  which  does  not  take  part  in  the 
development. 

The  glands  increase  in  size,  but  no  new  ones  are  formed.  In 
many  parts  their  upper  ends  become  indistinct  or  obliterated  owing 
to  the  lateral  pressure  of  the  surrounding  growing  decidual  cells. 
The  deeper  portions  are  enlarged  in  size,  so  that  the  spongy  nature 
of  the  lowest  part  of  the  mucosa  is  more  marked  than  in  the  non- 
pregnant state.  In  many  places  the  spaces  show  a  tendency  to  be 
arranged  with  their  long  axes  parallel  to  the  surface,  due  to  the 
increasing  pressure  of  the  developing  ovum.  The  glandular 
epithelium  becomes  greatly  altered  ;  in  most  parts  the  columnar 
shape  is  lost,  the  cells  becoming  cubical  or  somewhat  flattened. 


b    c 


i^SS^- 


i^sis^ 


Fig.  i8. — Section  through  posterior  wall  of  uterus  with  ovum  of  second  week 
{Leopold).  The  decidua  is  4  mm.  thick  at  fundus  (lO,  increases  to  6  and  8  mm.  {b,c) 
beside  ovum,  to  9  mm.  below  it  (d),  and  continues  about  8  to  6  mm.  down  to  os  inter- 
num {o.i.).  Beneath  the  ovum  the  serotina  is  only  4  mm.  thick.  The  mucosa  of  the 
cervix,  beyond  o.i,  is  not  altered. 

They  are  shed  singly  or  in  groups  into  the  lumen,  and  become 
greatly  degenerated. 

The  most  striking  change  in  the  mucosa  is  the  development 
of  the  decidual  cells,  which  commences  in  the  outermost  layer  of 
the  mucosa,  the  process  extending  downward  toward  the  spongi- 
osa.  In  their  well-formed  condition  the  decidual  cells  appear 
rounded,  oval,  polygonal,  or  spindle-shaped  (many  of  these  ap- 
pearances are  simply  due  to  the  different  planes  in  which  the  cells 
are  cut).  The  nuclei  are  large  and  somewhat  rounded.  In  most 
places  the  cells  are  connected  by  broad  or  slender  processes, 
although  sometimes  these  are  wanting.  Sometimes  the  spindle- 
shaped  cells  lie  in  compact  bundles,  the  individual  strands  appear- 
ing to  be  distinct  from  one  another.  Occasionally  smaller  bundles, 
torn  up  by  blood-extravasation,    may  be  noted;    the  processes 


PLA  CENT  A  TION. 


33 


connecting  many  of  the  cells,  whose  outlines  cannot  be  defined 
when  they  are  closely  packed,  may  easily  be  traced  when  they 
are  thus  separated.  Near  the  surface  of  the  vera  the  long  axes 
of  the  cells  lie,  for  the  most  part,  parallel  to  it.  The  earliest 
formation  of  decidual  cells  is  due  to  hypertrophy  of  the  connec- 
tive-tissue elements,  both  nucleus  and  cell-substance  sharing  in  the 
enlargement ;  the  proportion  of  the  latter  to  the  size  of  the  nucleus 
is  much  greater  than  in  the  non-pregnant  state.  New  cells  are 
also  formed  during  pregnancy,  being  especially  marked  in  the 
first  five  or  six  months.  There  is  no  ground  for  believing  that 
leukocytes  or  glandular  or  surface  epithelium  of  the  mucosa  share 
in  the  formation  of  the  decidual  cells. 

Marked  changes  take  place  in  the  blood-vessels.     In  the  com- 
pact layer  enormous  dilatation  of  the  capillaries  is  the  chief  feature, 


^Z 
m 

<^ 

^ 

<m> 

® 

<^ 

(S> 

Fig.  19. 


-Decidual    cells  from    compact  layer  of  vera  in  sixth  week  of  pregnancy. 
X  300. 


there  being  also  some  increase  in  the  size  of  the  arterioles  and 
venules  communicating  with  them.  Many  capillaries,  however, 
do  not  become  much  dilated,  and  maybe  very  little  altered.  Here 
and  there  small  extravasations  of  blood  are  found  among  the 
decidual  cells,  extending  into  the  lumen  of  the  glands  in  various 
places.  These  changes  in  the  mucosa  are  well  marked  during  the 
second  month ;  indeed,  the  highest  stage  in  progressive  develop- 
ment is  probably  reached  by  the  vera  in  the  early  part  of  this 
month,  though  the  period  is  probably  not  a  fixed  one,  but  varies 
in  different  cases.  By  the  fourth  month  the  surface  epithelium 
has  entirely  disappeared.  The  compacta  is  slightly  thinner  than 
it  was  in  the  second  month  ;  the  cells  lining  the  glands  are  to  a 
great  extent  separated  from  the  walls  and  degenerated.  Only  in 
a  few  places  can  a  section  of  a  gland  be  found  close  to  or 
between  the   muscular  bundles   with  a  well-preserved   epithelial 


34 


AA'jlTOA/V  AND   PHYSIOLOGY   OF  PREGNANCY. 


lining.  Both  in  the  superficial  and  deep  layers  of  the  mucosa 
very  slight  evidence  of  degeneration  is  found  in  some  of  the 
decidual  cells.  In  some  cases  the  cell-outlines  are  indistinct,  the 
matrix  appearing  swollen  and  staining  lightly.  Vacuolation  of 
nuclei  and  cell-sub.stance  is  found  here  and  there.  At  the  same 
time,  in  various  places,  cell-division  is  evident.  In  the  spongy  layer 
the  interglandular  trabecular  are  greatly  thinned.  Some  of  them 
are  broken  across  as  a  result  of  stretchino-  due  to  the  erowth  of 


D.v. 


Fig.  20. — Section  through  ovum  of  second  week,  embedded  in  decidua  (low  power) 
(Leopold):  M,  Muscular  wall  with  ends  of  glands  [dc]  in  it;  D.v,  decidua  vera 
divided  into  compact  (6'();«/.)  and  spongy  (Amp.)  layers.  The  mucosa  rises  at  w,w' 
around  ovum  to  form  the  reflexa  (or  decidua  capsularis,  Dc).  In  this,  up  to  d?-.  cp., 
gland  spaces  are  seen  ;  above  /,  /'  it  consists  mainly  of  fibrin.  'The  ovum  b,  b  is  at  one 
point  in  close  relation  to  a  decidual  elevation.  Between  it  and  the  surrounding  decidua 
many  villi  are  seen. 


the  uterine  musculature,  associated  with  a  disproportionate  rapid- 
ity of  growth  in  the  decidua.  Capillary  dilatation  is  still  found 
in  the  compacta,  but  the  sinuses  are  smaller  and  less  numer- 
ous than  in  the  second  month.  Thrombosis  is  found  in  several. 
The  intima  of  several  veins  and  arteries  is  thickened  as  a  re- 
sult of  proliferation  of  epithelium  or  of  the  connective-tissue 
elements. 

During  the  succeeding  months  of  pregnancy  the  vera  becomes 
thinner,  especially  in  the  compact  layer.    Elongation  of  the  gland- 


PLACENTATION.  35 

spaces  in  the  spongy  layer  and  their  tendency  to  he  parallel  to  the 
surface  become  more  marked.  The  blood-sinuses  have  to  a  very 
great  extent  become  obliterated.  At  full  time,  in  some  parts,  no 
compact  layer  worthy  of  the  name  can  be  found.  The  decidual 
cells  vary  greatly  in  appearance,  in  many  places  presenting  degen- 
eration, which  is  found  in  all  degrees,  though  it  is  interesting  to 
note  that  no  deeply  staining,  fibrin-like  masses  of  degenerated 
decidua  are  found  similar  to  those  in  the  serotina.  Occasionally 
fibrin  masses  resulting  from  old  extravasated  blood  may  be  seen 
in  the  vera. 

Decidua  Reflexa. — For  many  years  the  origin  of  the  decidua 
reflexa  in  the  human  female  has  been  the  subject  of  much  differ- 


.-."i^-i'l^'-^j^',':!'" 

4-t^       ^-l^Ca^ 

QT. 

\    ■' 

I-    i"p^^...  ...r---' 

Sy 

\. 

''.  'k 

1        '        " ;'        ■   '■■/■■•■-■ 

"H 

H          '^■-  '  "C-  .                    ■■-.  •. 

A/f- 

>.  ..^""' 

Jly 

(■     '.            """ 

—^Tr 

'\ 

•'•   ■/■'^-^':" 

I; 

■^M. 

Tr 

'■   o  4 

..?^''^W",  '•  :: 

:.:.'■'■■■■:,  '  ' 

■;;;V'"'  rv.'-^  y^''  :.' 

M.  . 

""'  '  -  rh- 

,    ,  ■'  "'    ■^■'. 

h'"'M    'f 

.4''\'':-'. 

Co.. 

- -"    ■-""^-•"■■;;:: 

Tr. 

"'"^  Iff. 

Fig.  21. — Section  through  ovum  embedded  in  the  mucosa.  Second  half  of  first  week 
of  pregnancy.  The  largest  diameter  of  the  chorionic  vesicle  is  seen  (H.  Peters):  G.P, 
Blood-clot  lying  on  the  outer  polar  portion  of  the  chorionic  vesicle  ;  a,  /;,  edges  of  open- 
ing in  mucosa  through  which  the  ovum  has  excavated  ;  [/.£,  uterine  epithelium  ;  Cap, 
decidua  reflexa ;  Tr,  trophoblast ;  Ca,  maternal  capillary ;  Dr,  gland  of  uterine 
mucosa;  Bl.L,  lacunae  in  the  trophoblast,  containing  maternal  blood;  K.A,  site  of 
embryo;  Comp,  decidua  compacta;  M,  fetal  mesoblast;  U.Z,  interglandular  tissue 
of  mucosa,  in  which  early  decidual  cells  are  found. 

ence  of  opinion  ;  very  widely  held  has  been  the  view  that,  when 
the  ovum  becomes  attached  to  the  mucosa,  projections  of  the  latter 
grow  up  around  it,  forming  a  complete  investment.  More  recently 
several  authorities  have  held  that,  as  the  ovum  attaches  itself  to 
the   growing  vera,  the   latter,  continuing   its   development,  soon 


36 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


surrounds  and  envelops  the  former,  the  reflexa  being,  therefore, 
merely  the  superficial  part  of  the  vera  which  has  grown  above 
and  over  the  ovum.  Hubert  Peters's  specimen  is  of  the  greatest 
interest  in  connection  with  the  origin  of  the  reflexa,  because  it  is 
the  earliest  stage  yet  secured.  Peters's  view  as  to  the  origin  is  as 
follows :  When  the  young  ovum  becomes  attached  to  the  mucosa 
it  rapidly  sinks  into  the  compacta,  thereafter  continuing  to  exca- 
vate laterally  as  well  as  deeply ;  the  overhanging  portion  of  the 
mucosa  forms  the  reflexa,  the  gap  through  which  the  ovum 
entered  being  closed  by  the  reorganization  of  blood-clot.     In  his 


Fig.  22. — Uterus  in  the  fourth  week  of  pregnancy.  The  anterior  wall  is  removed  to 
show  the  unopened  decidua  retle.xa.  The  latter  is  in  close  contact  with  the  decidua 
vera  ;  its  transverse  diameter  is  the  longest,  measuring  2.7  cm. ;  its  vertical  and  antero- 
posterior diameters  measure  about  2.5  cm. 

specimen  the  epithelium  on  the  outer  surface  was  cubical  near  the 
base,  but  flattened  toward  the  outer  portion  ;  near  the  gap  several 
cells  were  detached  and  lay  in  the  blood-clot.  In  the  basal  por- 
tion of  the  reflexa  the  glands  and  interglandular  tissue  were  similar 
to  those  of  the  neighboring  serotina.  The  tissue  was  edematous, 
the  capillaries  being  dilated  in  parts,  slight  extravasations  of  blood 
being  present.  In  later  specimens  decidual  formation  is  noted  in 
the  reflexa.  Degeneration  takes  place  in  the  cells  at  an  early 
period,  being  first  noticed  near  the  inner  surface  and  in  the  outer 
polar  portion  of  the  reflexa ;  indeed,  in  the  latter  area  very  little 


PLACENTATION. 


37 


else  than  fibrin  can  be  found  from  a  very  early  period  of  preg- 
nancy. 

The  innermost  layer  of  the  reflexa  soon  presents  an  almost 
continuous  layer  of  fibrin-like  material  of  regular  thickness,  most 
marked  near  the  outer  pole  of  the  reflexa.  This  appearance  is 
due  to  coagulation-necrosis  in  the  decidual  tissue,  'though  part 
of  the  surface  layer  may  be  fibrin  derived  from  blood.  No 
appearance  whatever  of  maternal  epithelium  can  be  found  at  any 
period  on  the  inner  surface  of  the  reflexa.  As  to  the  primary 
determining-   cause   of  the  necrotic  changes  in  the   reflexa  it   is 


Fig.  23. — .Section  through  reflexa  near  its  base.  Sixth  weeli  of  gestation.  X  30. 
a,  Reflexa;  b,  portion  of  vera;  c,  space  between  reflexa  and  vera;  d,  villi  of  chorion 
Iseve  ;  e,  syncytium  on  surface  of  reflexa ;  f,  fibrinous  degeneration  ;  g,  gland. 

impossible  to  speak  with  certainty.  They  are  probably  mainly  due 
to  imperfect  blood-supply.  At  first  the  reflexa  appears  to  be  well 
vascularized,  and  the  tissue  might  therefore  be  supposed  to  be  well 
nourished.  Possibly  owing  to  the  increase  of  decidual  cells,  the 
lymph-spaces  may  be  so  obliterated  as  to  lead  to  necrosis  at 
different  points,  this  change  being  further  as.sisted  by  the  pressure 
of  blood  effused  in  different  parts  of  the  reflexa.  Possibly,  also, 
the  circulation  is  slowed  by  the  outward  pressure  of  the  rapidly 
growing  ovum.     It  is  interesting  to  inquire  as  to  the  relation  of 


38  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 

this  hyaline  or  fibrinous  degeneration  to  changes  in  the  attached 
villi  of  the  chorion  laeve.  It  is  held  by  some  that  the  former  is 
secondary  to  the  latter.  Others  hold  that  the  relationship  is  one 
of  association  only,  both  the  reflexa  and  villi  degenerating  from 
causes  inherent  to  themselves.  It  is,  however,  possible  that  the 
degenerated  condition  of  the  reflexa  is  the  cause  of  retrogression 
in  the  villi  attached  to  it.  As  there  is  no  stimulus  to  increased 
o-rowth  of  the  latter,  owing  to  the  non-active  condition  of  the 
reflexa,  and  as  the  villi  are  bathed  for  a  short  time  only  with 
freely  circulating  maternal  blood,  they  do  not  functionate  for  more 
than  a  ver\'  short  period,  and  slowly  degenerate.  Apart  from 
the  intrinsic  degenerati\'e  changes  in  the  reflexa,  also,  must  be 
mentioned  the  part  played  by  mechanical  stretching  due  to  the 
increase  in  size  of  the  ovum.  As  to  the  function  of  the  decidua 
reflexa,  it  seems  merely  to  fix  and  stead}-  the  ovum  during  its 
early  life,  while  the  placental  circulation  is  being  established  ;  it 
probably  also  furnishes  slight  nourishment  to  the  ovum  through 
the  chorion  Ijeve,  but  this  is  of  minor  importance  and  of  brief 
duration. 

During  the  third  month  the  space  between  the  reflexa  and 
vera  begins  to  be  obliterated,  the  layers  being  in  close  contact, 
though  not  adherent.  Hitherto  it  has  been  generally  taught  that 
the  reflexa  blends  with  the  vera,  and  that  it  more  or  less  forms  the 
inner  layer  of  the  latter  during  the  advanced  months  of  preg- 
nancy. The  observations  of  Minot,  Frankel,  and  myself  have  cast 
doubts  upon  this  view.  During  the  fourth  month  I  have  found 
that  the  reflexa,  while  in  some  sections  noticeable  as  a  thin,  almost 
completely  fibrinous  or  hyaline  layer  in  contact  with  the  vera,  in 
others  is  entirely  absent,  the  chorion  laeve  lying  against  the  vera. 
At  this  period  there  is  very  little  degeneration  in  the  vera,  so  that 
it  is  quite  easy  to  distinguish  its  tissues  from  the  reflexa.  During 
the  remaining  months  of  pregnancy  small  portions  of  the  reflexa 
may  frequently  be  distinguished,  being  recognized  as  patches  of 
fibrin,  in  which  occasional  remains  of  degenerated  villi  are  found. 
Decidua  Serotina. — The  decidua  serotina  is  that  part  of  the 
vera  lying  between  the  muscular  layer  of  the  uterine  wall  and  the 
ovum  ;  to  it  the  latter  is  attached,  and  in  relation  to  it  the  placenta 
is  ordinarily  developed.  In  the  earliest  stage,  therefore,  the  sero- 
tina is  identical  with  the  vera,  save  that  its  outer  layer  is  altered 
as  a  result  of  the  embedding  of  the  ovum.  In  Peters's  early 
specimen  its  tissues  were  edematous  and  congested,  slight  extra- 
vasation of  blood  being  found  in  different  places.  Several  capil- 
laries were  much  dilated,  especially  near  the  surface,  forming 
blood-sinuses.  Some  of  these  were  completely  lined  with  endo- 
thelium ;  in  others  the  latter  was  more  or  less  stretched  and 
separated  from  the  wall  as  a  result  of  rapid  distention  of  the 
vessels.     The  earliest  stage  of  transformation  of  connective-tissue 


PLACENTATION. 


39 


cells  into  decidual  cells  was  observed.  In  some  of  the  glands 
loosening  and  degeneration  of  the  epithelium  had  begun,  the 
lumen  being  filled  with  blood  in  some  instances.  The  outer 
tissues  of  the  ovum  were  intimately  related  to  the  compact  layer, 
masses  of  proliferated  epiblast — trophoblast  extending  into  it  in 
all  directions.  At  various  points  maternal  blood-sinuses  com- 
municated with  lacunae  in  the  trophoblast,  the  maternal  blood 
circulating  through  the  latter.  There  was  no  evidence  of  trans- 
formation of  any  maternal  tissues  into  syncytium,  the  latter  being 
derived  from  changes  in  the  cells  lining  the  trophoblastic  lacunae. 
In  later  stages  of  pregnancy  the  decidual  cells  develop  as  has 


\ 


■IX^h^-. 


■fft. 


c    '< 


Vv   /'■" 


Fig.  24. — Superficial  portion  of  decidua  vera.  Sixth  week  of  gestation.  X  30. 
a,  Compact  decidual  tissue;  b,  surface  of  vera,  on  which  the  epithelium  is  somewhat 
flattened,  degenerated,  and  separated;  c,  capillaries  dilated  to  form  blood-sinuses;  d, 
portions  of  glands,  in  some  of  which  the  lining  epithelium  is  cast  off. 


been  described  in  connection  with  the  vera,  variations  being  found 
in  them  in  regard  to  size,  shape,  and  arrangement.  Degenerative 
changes  take  place  from  an  early  period.  By  the  sixth  week  the 
superficial  part  of  the  compact  layer  is  occupied  by  an  irregular 
layer  of  hyaline  or  fibrinous  material,  which  stains  deeply  with 
eosin.  From  it  processes  extend  inward,  varying  considerably  in 
their  staining  reaction.  In  this  layer  many  outlines  of  altered 
decidual  cells  may  be  found. 

It  is  interesting  to  note  that  in  the  vera  no  such  appearance  is 
found  save  close  to  the  serotina,  degeneration  taking  place  in  the 
former  much  more  slowly  and  to  a  less  marked  extent. 


40 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


c^'^:--  CL- 


Fig.  25. — Portion  of  spongy  layer  of  serotina.  Sixth  week  of  gestation.  X  4°- 
a,  Remains  of  gland-spaces  pressed  somewhat  parallel  to  the  uterine  musculature  and 
containing  cast-off  degenerating  glandular  epithelium;  b,  decidual  tissue  of  inter- 
glandular  trabeculas. 

As  pregnancy  advances,  after  the  early  weeks  the  surface  of 
the  serotina  is  often  found  to  be  irregular,  small  projections  being 


Fig.  26. —  Portion  of  decidua  serotina.     Fourth  month  of  gestation.     X  300.     a,  Anas- 
tomosing decidual  cells;  b,  remains  of  epithelium  lining  gland-lumen. 

found,  varying  in  height  and  irregularly  distributed.    In  some  cases 
these  are  very  few  and  small. 


Plate  2. 


A/- 


/- 


/ 


IIV 


W^HRER 


Section  through  wall  of  pregnant  uterus  at  edge  of  placenta  (near  full  time)  : 
a,  Decidua  serotina  ;  b,  decidua  vera  ;  c,  spongy  layer  of  decidua  ;  d,  muscular 
wall  ;  e,  layer  of  decidua  extending  for  short  distance  under  chorion  at  edge  of 
placenta  ;  /,  circular  sinus  (so-called)  at  edge  of  placenta  ;  _g,  chorionic  epithelium  ; 
h,  amnion  ;  ?',  villi  of  placenta  ;  /,  maternal  blood  in  intervillous  space  ;  k,  deeply 
staining  ribrinr)us  layer  at  surface  of  decidua  ;  /,  blood-sinus  in  decidua. 


PLA  CENTA  TION. 


41 


At  the  fourth  month  the  average  thickness  of  the  serotina  is 
less  than  it  was  during  the  second  month,  the  reduction  having 
occurred  both  in  the  compact  and  spongy  layers.  Many  of  the 
glands  are  obliterated  or  compressed,  their  epithelium  being  degen- 
erated ;  in  their  outer  parts  near  the  muscle  they  are  greatly  elon- 
gated and  tend  to  lie  parallel  to  the  latter.  Masses  of  syncytium 
are  irregularly  scattered  through  the  whole  decidua,  being  also 
found  in  the  adjacent  parts  of  the  musculature.  They  are  found  in 
the  connective  tissue,  in  blood-sinuses,  in  veins,  and  occasionally 
in  the  lumen  of  glands.  In  several  places  the  walls  of  vessels  are 
surrounded  with  thick  fibrin  ;  in  some  vessels  endothelial  prolifer- 
ation is  found.  As  pregnancy  advances  further  thinning  of  the 
serotina  takes  place,  with  increasing  degeneration  of  the  tissue, 
though  in  many  parts  some  undegenerated  decidual    cells  may 


a                      e 

■: 'v' %'•/;. ' ■' .■'■"I. ■■  "''■''- 

*'."'•     /  ,  *  .'           .  *■-  ■  ^  '   ■  '  .^          ■'.  -^           ^  ],- 

■'    ,            «■"'""','        "   .       '   ■         •  ^                    '■    -^     ' 

."■•■-■-■•V-*:-    ,■'•'•"..-'■*        "-  -  '    *•'«*♦•.  "^SiTT-  <? 

"  •  ■            ■<"     -    ,%•.»•■"'*"'?.•  ^  ■  .-.'■>  \^-  ■' 

Fig.  27. — Portion  of  compact  layer  of  serotina.     Fourth  month  of  gestation.     X  40- 
a,  Decidua  serotina;  i>,  gland-space;  c,  mass  of  syncytium  among  the  decidual  cells. 

continue  to  be  found.  Masses  of  syncytium  in  the  decidua  are 
relatively  less  abundant  than  at  an  earlier  period.  More  marked- 
thickening  of  the  intima  is  noticed  in  many  of  the  vessels. 

At  full  time  the  serotina  varies  greatly  in  different  portions. 
At  some  places  it  is  almost  absent,  only  a  thin  layer  of  decidua 
intervening  between  the  muscular  layer  and  the  villi.  In  a  few 
parts  it  is  entirely  wanting,  the  villi  lying  against  the  muscle. 
These  portions  must  have  been  thin  in  the  beginning,  their  dis- 
appearance having  been  due  to  mechanical  stretching  as  well  as 
to  physiologic  absorption.  Over  a  large  extent  its  thickness 
measures  only  from  o.  I  to  I  mm.  Here  and  there  narrow  and 
broad  hillocks,  mostly  of  low  elevation,  project  from  the  surface, 
being  rarely  higher  than  1.5  mm. 

The  compact  and  spongy  layers  vary  in  appearance  in  different 
places  ;  the  trabeculae  of  the  latter  are  narrow  and  in  many  places 


42 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY, 


broken.  In  the  compacta  very  i^tw  traces  of  glands  exist,  their 
epithelium  being  entirely  absent.  In  the  spongy  layer  the  epithe- 
lial debris  has  largely  disappeared  from  the  gland-spaces.  The 
decidual  tissue  presents  varied  appearances  :  the  superficial  por- 
tions of  the  compacta  are  largely  changed  into  fibrinous  material, 
staining  deeply,  some  parts  being  dense,  others  loose  and  vacuo- 
lated. In  it  cell-outlines  may  occasionally  be  distinguished,  the 
nuclei  being  observed  in  various  stages  of  degeneration,  those 
areas  in  which  cell-outlines  and  nuclei  are  most  easily  seen  stain- 
ing less  deeply  than  the  distinct  fibrinous  portions.  In  other  parts 
well-formed  decidual  cells  are  seen,  those  nearest  the  surface  lying 
more  or  less  parallel  to  it ;  they  stain  with  varying  intensity. 
Here  and  there  masses  of  well-marked  branching  and  anasto- 
mosing; cells  are  found  with  one  or  more  nuclei.    In  the  trabeculae 


Fig.  28. — Section  from  full-time  pregnant  uterus.  X  60.  a.  Decidual  cells  of 
serotina  ;  b,  fibrinous  degeneration  in  superficial  portion  of  decidua  ;  c,  fibrinous  degen- 
eration in  deeper  portion  of  decidua ;  d,  syncytium  on  surface  ;  e,  syncytial  mass  in 
decidual  tissue  ;  f,  villus. 

of  the  spongy  layer  the  cells  are  not  so  large  as  in  the  compacta, 
the  largest  being  found  near  the  latter. 

The  blood-sinuses  vary  considerably  in  size,  shape,  and  appear- 
ance, many  of  them  are  contracted  by  fibrinous  thickening  around 
them,  or  by  endothelial  proliferation.  In  some  places  the  vessels 
are  closed  by  the  pressure  of  blood-extravasation  around  them*. 
Masses  of  syncytium  are  distributed  as  has  already  been  described. 

Nature  of  the  Progressive  Changes  in  the  Decidua. — It  has 
been  pointed  out  that  the  decidua  reaches  its  highest  development 
at  some  time  during  the  second  month.  At  the  end  of  pregnancy 
it  is  diminished  in  thickness. 

Changes  Mechanical  in  Nature. — The  thinning  is  partly  due  to 
pressure  of  the  uterine  contents  as  well  as  to  the  great  stretch- 
ing that  takes  place  in  a  direction  parallel  to  the  surface.     These 


PLACENTATION.  43 

mechanical  alterations  are  evident  from  the  arrangement  of  the 
gland-spaces  parallel  to  the  surface  as  pregnancy  advances,  from 
the  thinning  of  the  trabecular  of  the  spongy  layer  and  the  tearing 
across  of  them  during  the  later  months.  The  general  tendency 
of  the  decidual  cells  to  lie  more  or  less  parallel  to  the  surface 
should  also  be  noted.  The  loose  arrangement  of  decidual  cells 
found  in  various  parts  may  also  be  caused  by  the  stretching. 

In  the  early  months  the  same  influences  cause  portions  of  the 
surface  and  the  glandular  epithelium  to  be  cast  off. 

C/iang-cs  Non-vieclianical  in  Nature. — The  degeneration  and 
disappearance  of  the  glandular  epithelium  is  now  beyond  dispute. 
The  view  of  those  who  hold  that  it  is  transformed  into  syncytium 
is  utterly  untenable.  The  degeneration  may  be  mainly  mechan- 
ical— /.  e.,  the  cells  may  become  flattened  and  separated  as  the 
result  of  the  rapid  increase  and  stretching  of  the  interglandular 
tissue,  but  it  also  may  be  due  to  the  choking  of  the  lymphatics 
by  the  decidual  proliferation,  leading  to  interference  with  the 
nutrition  of  the  epithelium,  in  the  compacta  at  least.  The 
glandular  epithelium  of  the  compact  layer  always  degenerates 
before  that  of  the  spongy  layer  ;  the  latter  is  probably  mainly 
affected  by  the  mechanical  influences.  The  most  important  de- 
generation in  the  interglandular  tissue  is  coagulation-necrosis, 
which  gives  rise  to  the  hyaline  or  fibrinous  areas  so  constantly 
found  in  the  serotina.  It  is  usually  found  in  the  reflexa  before 
it  appears  in  the  serotina  ;  in  the  latter  it  is  present  by  the  sixth 
week.  It  is  chiefly  found  in  the  superficial  portion  of  the  com- 
pacta, although  it  may  extend  downward  to  a  varying  extent  in 
different  places.  It  frequently  marks  the  outermost  limit  of  the 
decidua,  but  occasionally  a  thin  layer  of  unaltered  decidua  may 
be  found  above  it.  Though  degeneration  occurs  in  the  cells  of 
the  decidua  vera,  characteristic  deeply  staining  hyaline  areas  are 
not  found  in  it.  In  seeking  for  an  explanation  of  the  difference 
between  the  degree  of  degeneration  in  the  reflexa  and  serotina 
and  that  in  the  vera,  an  important  influence  may  possibly  be 
attributed  to  the  fetal  structures  in  relation  to  the  reflexa  and 
serotina ;  certainly,  in  the  early  appearance  of  the  degeneration, 
it  is  generally  related  to  that  portion  of  the  decidua  to  which  vilU 
are  attached.  It  is  possible,  also,  that  the  fibrinous  layer  on  the 
inner  surface  of  the  reflexa  may  be  derived  from  maternal  blood 
lying  between  the  villi  which  bathe  the  surface  of  the  reflexa  and 
serotina  in  the  early  weeks.  Another  factor  favoring  the  degen- 
eration may  be  that  which  has  already  been  mentioned  in  connec- 
tion with  the  degeneration  of  the  surface  epithelium — compression 
and  obliteration  of  lymph-spaces  as  well  as  of  many  capillaries 
that  do  not  dilate  to  form  blood-sinuses,  leading  to  interference 
with  the  nutrition  of  the  superficial  area  of  the  decidua,  especially 
with  that  part  which  forms  the  reflexa.     Owing  to  the  spongy 


44 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


character  of  the  lower  portion  of  the  decidua  there  is  little  danger 
of  interference  with  its  nutrition.  It  is  possible,  also,  that  the 
early  rapid  formation  of  the  blood-sinuses  in  the  compact  layer 
may  increase  the  pressure  on  surrounding  cells.  Fatty  degenera- 
tion is  very  rare  in  the  decidua  except  in  pathologic  conditions. 
Absorption  of  Decidua. — Absorption  of  degenerated  decidual 


Fig.  29. — Section  from  uterus  111  fourth  week  of  pregnancy:  a,  Decidua  vera;  b, 
portion  of  uterine  musculature;  c,  compact  layer  of  vera;  d,  spongy  layer  of  vera;  c, 
compact  layer  of  serotina  ;  f,  decidual  hillock;  g,  spongy  layer  of  serotina;  h,  blood- 
sinus  in  serotina ;  /,  chorion  ;  /,  villi  of  chorion  frondosum  ;  k,  villi  of  chorion  Iseve  ; 
/,  fibrin  on  inner  wall  of  decidua  refiexa,  in  which  villi  are  embedded  ;  ;«,  basal  portion 
of  refiexa  ;  ;/,  outer  polar  portion  of  reflexa  ;  o,  amnion  ;  /,  umbilical  cord  ;  q,  amniotic 
cavity. 

tissue  takes  place  during  pregnancy,  at  least,  after  the  first  two  or 
three  months.  The  removal  is  brought  about  either  by  the 
maternal  blood  or  lymph  or  through  the  agency  of  leukocytes. 
Its  disappearance  may  also  be  partly  due  to  the  action  of  the 
fetal  epiblast.  The  trophoblastic  nature  of  the  latter,  first  de- 
scribed by  Hubrecht  in  the  case  of  the  hedge-hog,  has  been 
demonstrated  in  other  mammals,  and  may  be  considered  as  well 


PL  A  CENTA  TION.  45 

established  in  the  human  female.  But  degeneration  and  absorp- 
tion are  not  the  only  changes  that  occur  in  the  decidua  during 
pregnancy.  New  formation  of  tissue  occurs  constantly,  especially 
in  the  early  months  ;  and  were  it  not  for  this  it  is  certain  the 
mechanical  stretching,  compression,  and  thinning  of  the  decidua, 
along  with  degeneration  and  absorption,  would  cause  its  entire 
disappearance  before  the  end  of  pregnancy.  Indeed,  at  full  time 
the  serotina,  in  certain  parts,  may  have  disappeared  entirely,  or 
almost  entirely,  because  the  formative  activities  of  the  tissues  are 
unable  to  counterbalance  the  influence  of  the  destructive  agencies. 
Throughout  pregnancy  areas  of  well-formed  active  decidual  cells 
may  be  noted,  and  these  are  probably  mainly  instrumental  in 
making  up  for  the  losses  that  are  sustained. 

Barly  Relations  between  the  Ovum  and  Decidua. — 
Until  the  publication  of  Peters 's  work  all  statements  as  to  the 
early  relationships  between  the  ovum  and  decidua  were  specula- 
tive. His  sections  have  added  much  to  our  knowledge,  and  must 
be  briefly  noted. 

The  chorionic  vesicle  in  his  specimen  was  a  lenticular  mass, 
measuring  3,  1.5,  1.5  mm.  in  its  three  diameters,  the  longest  being 
parallel  to  the  serotina.  It  was  embedded  in  the  outer  part  of  the 
compacta  save  at  its  outer  polar  portion,  where  there  was  an  area 
I  mm.  in  diameter  covered  only  by  blood-clot,  which  closed  the 
gap  in  that  part  of  the  decidua  under  which  the  ovum  had 
excavated.  No  remains  of  maternal  surface  epithelium  were 
found  under  the  ovum.  All  around  the  vesicle  was  a  marked 
development  of  epiblast — the  trophoblast — thicker  next  the  sero- 
tina than  on  the  outer  surface  of  the  vesicle.  It  was  not  solid, 
but  consisted  of  irregular  spaces,  between  which  were  lacunae  of 
various  sizes,  many  of  which  were  filled  with  maternal  blood 
derived  from  dilated  capillaries  in  the  superficial  layer  of  the 
compacta.  Internal  to  the  trophoblast  lay  a  thin  layer  of  fetal 
mesoblast,  which  extended  for  a  slight  distance  outward,  at  differ- 
ent points,  into  shallow  depressions  in  the  trophoblast.  The  cells 
of  the  latter,  distinct  from  one  another,  formed  several  layers, 
those  next  the  fetal  mesoblast  being  somewhat  cubical ;  those  of 
the  outer  layers  being  somewhat  rounded  in  outline.  The  nuclei 
were  large,  round  or  oval,  finely  granular,  and  staining  deeply. 
In  the  outer  portions  the  cells  were  more  irregular,  some  of  them 
being  vacuolated.  In  many  of  the  lacunae  of  the  trophoblast 
which  were  occupied  by  maternal  blood  the  lining  consisted  of  a 
nucleated  protoplasm  in  which  no  cell-outlines  could  be  distin- 
guished. The  latter  was  regarded  by  Peters  as  the  earliest  stage 
in  the  formation  of  .syncytium,  and  consisted  in  a  fusion  of  the 
trophoblastic  cells,  brought  about  partly  by  the  pressure  of  the 
blood,  partly  by  the  influence  of  the  blood-plasma  ;  broken-down 
blood-corpuscles  seemed  to  fuse  with  the  cells  in  some  parts. 


46 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


At  different  points  the  outer  processes  of  the  trabeculae  pene- 
trated maternal  blood-sinuses,  the  communication  with  the  troph- 
oblastic lacuna?  being  undoubtedly  established  in  this  way.  The 
trophoblastic  strands  between  the  lacunae  are  to  be  regarded 
as  the  primitive  villi,  being  entirely  epiblastic.  During  the  second 
week  the  fetal  mesoblast  begins  to  penetrate  them,  forming  the 
connective-tissue  core,  in  which  capillaries  gradually  develop. 
Many  of  the  strands  attached  to  the  decidua  give  rise  to  future 


Fig.  30. — Section  through  outer  portion  of  trophoblast  and  adjoining  decidua. 
First  week  of  pregnancy  (H.  Peters) :  7>,  Trophoblast ;  Sy,  earliest  formation  of 
syncytium;  B/.L,  lacunse  in  the  trophoblast  filled  with  maternal  blood;  U.Z,  con- 
nectiye  tissue  of  uterine  mucosa,  in  which  early  decidual  cell-formation  is  beginning. 

permanent  villus-stems.  New  villi  very  soon  begin  to  develop, 
the  earliest  forms  being  buds  of  fetal  epiblast.  The  original 
lacunae  in  the  trophoblast  increase  in  size,  forming  the  permanent 
intervillous  space,  in  which  the  maternal  blood  circulates  around 
the  villi.  On  the  surface  of  the  decidua  is  found  a  well-marked, 
irregular  layer  of  plasmodial,  nucleated  protoplasm  identical  with 
the  syncytium  found  on  the  outer  part  of  the  chorion  and  villi, 
and  in  many  places  continuous  with  it.  Irregular  masses  of  this 
syncytium,    some    of    which    are    reticulated,    project    from    the 


PLATE  3. 


Diagrammatic  representation  of  relationship  of  ovum  to  decidua  :  I,  In  latter 
half  of  first  week  ;  2,  a  few  days  later  ;  3,  a  few  months  later,  when  placenta  is 
well  defined  :  <?,  fetal  mesoblast,  showing  indications  of  beginning  extension  into 
trophoblast  stalks  in  i,  actual  extension  in  2  and  3  ;  /',  trophoblast,  being  reduced 
in  3  and  constituting  here  the  layer  of  Langhans  ;  c,  trophoblast  lacuna  in  i,  en- 
larged in  2  and  3  as  an  intervillous  space  ;  d,  syncytium,  seen  in  its  earliest  stage  in 
I  ;  e,  decidua;  f,  maternal  blood-sinus;  g,  endothelium  lining  maternal  sinus;  h, 
epiblastic  covering  of  cord;  i,  amniotic  epiblast;  /,  umbilical  vein;  k,  umbilical 
artery  ;  /,  amniotic  mesoblast ;  ;«,  extension  of  decidua  on  under  surface  of  chorion 
at  edge  of  placenta  ;  w,  large  villus-stem. 


PLACENTATION. 


47 


decidual  surface  into  the  intervillous  spaces,  and  portions  extend 
as  well  downward  into  the  substance  of  the  decidua.  This  syn- 
cytium found  on  the  surface  of  the  decidua  is  derived  from  the 


Fig.  31. — Human  ovum  of  about  twelve  days  (Reichert):  A,  Side  view;   B,  front  view. 
The  villi  are  seen  to  be  limited  in  distribution,  leaving  the  poles  free. 

outermost  portions  of  the  trophoblast,  which  are  pressed  against 
the  decidua  as  the  blood  increases  in  the  intervillous  spaces.  It 
may,  therefore,  be  regarded  as  a  remnant  of  the  early  trophoblastic 


-^'y 

^'1 

.     .'^^■-'^ 

-  .'■  / 

BlL 

'4 

'v' 

■^          ':■:■: 

Eki  . 

.■;■  ■-■:■>:  « 

Tr 

3 

-../.,->.' 

."<•'■■:' 

BIL 

■■-■;■  i'-'/V     »  •   ■ 

.Ns'-- 

"•\^ 

^'<^, 

•      ^^*^'     -■ 

*.S*KSS. 

T-r 

Fig.  32. — Section  through  the  chorionic  epiblast  layer  and  part  of  its  trophoblastic 
extension.  First  week  of  pregnancy  (H.  Peters)  :  Eki,  Chorionic  epiblast;  Tr,  tropho- 
blast; Sy,  earliest  syncytium;  Bl.L,  lacunas  in  the  trophoblast,  into  which  maternal 
blood  has  found  its  way. 

connection  between  the  chorionic  vesicle  and  the  decidua.  As 
regards  the  function  of  the  early  marked  epiblastic  proliferation, 
the  following  may  be  suggested  : 


48  ANATOMY  AND  PHYSIOLOGY  OF  PREGNANCY. 

1.  It  helps  to  fix  the  ovum  to  the  decidua. 

2.  The  trabeculae  of  the  early  reticulum  are  the  pathfinders 
for  the  future  permanent  villi. 

3.  Absorption  of  nourishment  is  undoubtedly  an  important 
function,  and  there  can  be  no  doubt  that  the  early  embedding  of 
the  ovum  is  accompanied  by  direct  absorption  of  the  tissue  and 
fluids  of  the  decidua  by  means  of  the  fetal  epiblast. 

4.  The  trophoblastic  extensions  also  serve  to  establish  a  con- 
nection between  the  maternal  blood  and  the  fetal  tissues  by  eating 
through  the  decidua  and  walls  of  the  sinuses.  As  soon  as  the 
blood  enters  the  lacunae  in  the  trophoblast  nourishment  is  prob- 
ably taken  from  it,  though  there  is  as  yet  no  fetal  circulation  in 
the  early  epiblastic  stalks. 

Throughout  pregnancy  syncytial  remains  are  found  on  the 
decidua  and  in  its  substance,  extending  into  sinuses,  gland  spaces, 
and  veins,  even  reaching  below  into  the  musculature.  They  are 
mainly  limited  to  the  serotina,  being  also  found  to  a  slight 
extent  in  the  early  reflexa.  They  are  not  found  in  the  decidua 
vera  except  occasionally  immediately  adjacent  to  the  serotina,  from 
which  syncytial  projections  may  extend  outward  obliquely  into 
the  vera  for  a  short  distance.  After  the  obliteration  of  the 
reflexa,  when  the  remains  of  the  chorion  laeve  come  into  relation- 
ship with  the  vera,  small  irregular  portions  of  syncytium  may  be 
found  on  the  surface  of  the  latter.  That  the  syncytium  is  entirely 
fetal  in  origin  cannot  be  disputed.  If  the  vera  and  serotina  be 
compared  at  the  sixth  week,  before  the  reflexa  is  obliterated,  not 
a  trace  of  syncytium  is  found  on  or  in  the  vera ;  whereas,  it  is 
abundantly  present  in  the  serotina.  The  view  that  the  syncytium 
is  derived  from  the  uterine  epithelium  cannot  be  maintained. 

Chorion. — The  chorion  is  best  described  as  the  outermost 
covering  of  the  blastodermic  vesicle,  which  enters  into  direct 
relationship  with  the  decidua  serotina  and  decidua  reflexa.  This 
layer  is  at  first  entirely  epiblastic,  a  thin  layer  of  mesoblast,  how- 
ever, very  soon  developing  internal  to  it.  On  entering  into  rela- 
tionship with  the  decidua  the  epiblast  increases  in  thickness,  form- 
ing the  trophoblast,  already  described,  which  soon  becomes  reticu- 
lated owing  to  the  development  of  lacunae  in  its  substance.  These 
lacunae  are  the  earliest  stage  in  the  formation  of  the  future 
intervillous  spaces  ;  maternal  blood  very  early  enters  into  them, 
communication  with  the  maternal  sinuses  being  established  by  the 
trophoblastic  strands.  The  trabeculae  between  the  lacunae  are  to 
be  regarded  as  the  earliest  villous  formations.  Into  them  projec- 
tions gradual!}^  extend,  commencing  early  in  the  second  week. 
The  transformation  of  the  cells  lining  the  lacunae  into  syncytium 
has  already  been  described.  The  latter  gradually  increases  so  as 
to  form  a  well-marked  layer  covering  the  outer  part  of  the  entire 
chorion,  the  deeper  portion  being  the  unaltered  epiblastic   cells. 


PLACENTA  TION.  49 

During  the  second  week  these  layers  are  well  defined,  the  deep 
layer  consisting  of  cubical  or  round  cells,  lying  in  close  contact 
with  the  fetal  mesoblast ;  they  possess  well-marked  outlines,  lightly 
staining  cell-substance,  and  round  or  oval  nuclei.  This  layer  is 
generally  known  as  the  Langhans  layer. 

The  superficial  syncytial  layer  is  composed  of  darkly  staining 
granular  protoplasm,  nucleated  but  without  distinct  cell-outlines. 
It  varies  in  thickness  in  different  places,  the  nuclei  being  massed 
together  at  intervals  in  large  numbers ;  here  and  there  projections 
extend  into  the  intervillous  spaces.  The  syncytium  probably  acts 
as  a  kind  of  endothelial  lining  of  the  intervillous  spaces,  and  may 
play  some  important  part  in  the  physiologic  interchange  which 
takes  place  between  the  fetal  and  maternal  blood  during  preg- 
nancy. It  probably  also  exercises  an  influence  in  preventing 
coagulation  of  the  maternal  blood.  The  chorionic  mesoblast,  in 
its  earliest  state,  is  a  thin  layer  containing  from  two  to  four  thick- 
nesses of  cells,  which  are  round,  oval,  or  spindle  shaped.  Very 
soon  branching  is  noted  in  them. 

In  all  early  specimens  the  chorionic  villi  are  mostly  unbranched; 
some  are,  however,  slightly  branched.  They  extend  outward  at 
right  angles  or  obliquely  from  the  chorionic  surface  and  run  a 
straight  or  wavy  course.  Many  variations  are  found  as  regards 
the  extent  to  which  the  syncytium  is  developed  on  them,  as  well 
as  regards  the  thickness  of  the  mesoblastic  core  and  the  extent  to 
which  capillary  formation  has  taken  place  in  them.  Some  of  the 
villi  may  be  attached  to  the  decidua  merely  by  a  stalk  of  syncy- 
tium. The  majority  become  attached  by  a  proliferation  of  the 
Langhans  layer  of  epiblast  at  their  ends,  forming  a  thick  mass  of 
cells.  The  syncytial  layer  on  the  surface  of  the  mass  becomes 
stretched,  thinned,  and  more  or  less  broken  off. 

The  description  of  the  chorion  thus  given  applies  to  all  parts 
of  it  during  the  early  days  of  gestation.  Thereafter  it  must  be 
described  in  two  portions  : 

1.  The  chorion  frondosum  or  placental  part. 

2.  The  chorion  Iseve  or  non-placental  part. 

Placental  Part  of  the  Chorion. — By  the  second  half  of  the 
second  month  the  villi  have  become  more  numerous  and  more 
branched.  The  branches  can  be  traced  in  all  stages  of  their 
development,  from  solid  buds  or  strands  to  those  which  are  vacu- 
olated and  to  those  which  contain  mesoblast.  The  proliferative 
activity  of  the  epiblast,  which  is  very  marked  in  the  early  months, 
diminishes  as  pregnancy  advances. 

In  fairly  well-formed  villi,  at  the  end  of  the  second  month,  the 
Langhans  layer  consists  of  a  single  or,  in  some  parts,  a  double 
row  of  cells,  whose  protoplasm  stains  more  lightly  than  that  of 
the  syncytial  layer.  The  outer  or  syncytial  layer  is,  on  the  aver- 
age, much  thicker  than  the  Langhans  layer;  in  many  parts  the 


50 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


cells  of  the  latter  are  more  or  less  separated  from  one  another. 
Slight  degeneration  may  be  noted  in  the  syncytium,  indicated  by 
vacuolation,  by  a  tendency  to  split,  and  by  deeper  staining  of 
some  parts  than  of  others.  Aschoff  states  that  it  is  normal  to 
find  fat  in  the  syncytium.  The  chorionic  mesoblast  is  more 
fibrillated  than  during  the  earlier  weeks,  and  appears  condensed 
in  parts.  It  contains  more  spindle-shaped  cells,  which  usually 
lie  parallel  to  the  surface.  In  the  villous  stems  the  mesoblast  is 
most  condensed  at  the  periphery  and  at  the  outer  ends.  In  the 
small  villi  it  is  quite  loose,  of  the  delicate  mucoid  type.  Most  of 
the  villi  contain  capillaries  consisting  of  tubes  of  small  flat  endo- 
thelial cells,  around  which  the  connective  tissue  is  somewhat  con- 
densed, though  to  a  varying  extent  in  different  places.  Among 
the  villi  are  free  pieces  of  syncytium,  irregular  in  shape  and  size, 
and  presenting  the  same  appearance  as  the  buds  and  processes 


<^^  ' 

.  ^mm^ 

m^Mk 

«      « 

<«^2r 

—  CL^ 

mS^ 

-b 

*• 

•.            •^  " 

t^A 

--^  -4^ 

s*>  •. 

I#^ 

if? 

c 

Fig.  33. — Bud  of  syncytium  from  intervillous  space.  Fifth  week  of  gestation. 
X  350.  a,  Deeply  staining  nuclei  of  various  sizes  in  undifferentiated  matrix  ;  d,  early 
stage  of  vacuolation  ;  c,  mesoblast  penetrating  a  vacuolated  portion. 

attached  to  the  villi ;  they  are  evidently  sections  of  the  latter.  The 
villi  are  attached  indiscriminately  to  elevations  and  depressions  on 
the  decidual  surface.  In  some  cases  a  pit-like  depression  may  be 
occupied  by  a  villus,  which  may  thus  seem  to  be  compressed  by 
the  surrounding  decidual  tissue.  This  appearance  has  often  erro- 
neously been  interpreted  as  a  boring  of  the  villus  into  the  serotina; 
while  the  ends  of  the  villi,  by  means  of  their  epithelium,  undoubt- 
edly do  absorb  the  decidua  to  a  slight  extent,  there  is  never  any 
deep  extension  into  the  serotina.  As  pregnancy  advances  the 
connective  tissue  of  the  chorion  and  villi  becomes  denser  and 
more  fibrillated  ;  the  epithelium  gradually  thins,  the  syncytium 
splitting  to  a  greater  extent  and  undergoing  hyaline  degeneration 
and  vacuolation.  At  the  end  of  pregnancy  the  conditions  are  as 
follows :  Here  and  there  one  or  more  villi  may  be  embedded  in  a 
mass  of  fibrin,  the  epithelium  of  the  villi  being  absent,  their  con- 


PLA  CENT  A  TION. 


51 


Fig.   34. — Villus-stem   and  branching  villi  in  the   fifth   month  of  gestation  (Bumm) : 
a,  Decidua  serotina  ;  b,  chorion. 

nective  tissue  being  dense,  and  their  vessels  more  or  less  obliter- 
ated.    The  fibrin  may  be  dense  and  fibrillated  or  it  may  have  a 


OL 


fl"^-  35- — Villi  attached  to  serotina.  Sixth  week  of  gestation.  X  90.  a,  Serotina  ; 
b,  villus-stem;  c,  proliferation  of  Langhans  cells  attaching  villus-stem  to  serotina; 
d,  mass  of  syncytium  in  the  serotina. 


52 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


loose,  reticulated  structure.  Scattered  through  it  may  be  found 
pieces  of  epithelium  in  various  stages  of  degeneration.  The  villi 
in  general  are  relatively  more  attenuated  than  in  early  pregnancy. 
In  the  large  ones  the  connective  tissue  is  uniformly  or  irregularly 
dense,  especially  around  the  vessels.  There  is  a  relatively  large 
proportion  of  matrix  to  cells  ;  many  of  the  latter  are  shrivelled, 
lying  in  spaces.  In  the  small  villi  the  connective  tissue  is  for  the 
most  part  loose  and  mucoid.  Many  of  the  vessels  are  diminished 
in  caliber,  especially  in  the  larger  villi,  owing  to  the  thickening  of 
the  intima  or  of  the  connective  tissue  around  them,  or  to  both  of 
these  conditions.  Hyaline  degeneration  may  be  occasionally  found 
in  the  vessel-walls.  The  endothelium  may  be  both  proliferated 
and  swollen.  The  epithelial  covering  of  the  villi  differs  consider- 
ably from  the  condition  found  in  early  pregnancy.    In  many  parts 


Fig.  36. — Portion  of  injected  villus  from  a  placenta  of  about  five  months  (Minot) 


it  consists  of  a  layer  containing  cubical  or  flattened  nuclei,  evidently 
the  remains  of  the  syncytium,  no  cell-outlines  being  recognizable; 
the  nuclei  may  be  close  together  or  more  or  less  separated ;  they 
are  finely  granular  and  stain  deeply.  In  some  places  the  syncy- 
tium occurs  in  masses  of  various  shapes  and  sizes ;  in  many  parts 
it  is  degenerated  and  split  up.  Occasionally  a  strip  may  be  sepa- 
rated, resembling  an  endothelial  layer.  Here  and  there  the  con- 
nective-tissue core  of  the  villi  is  quite  bared,  being  directly 
bathed  by  maternal  blood  in  the  intervillous  space.  Very  few 
cells  of  the  Langhans  layer  are  found  ;  they  may  be  somewhat 
flattened,  and  are  usually  separated  more  or  less  from  one  another. 
In  parts  the  surface  epithelium  is  entirely  replaced  by  a  deeply 
staining  fibrinous  layer.  A  few  buds  of  syncytium  project  from 
the  chorion,  and  few  detached  projections  are  found  among  the 


PLACENTA  TION. 


53 


villi.  In  most  of  the  villi  attached  to  the  decidua  the  proliferated 
cells  of  the  Langhans  Jayer,  at  their  outer  ends,  have  disappeared, 
so  that  the  connective  tissue  of  the  villus  is  in  direct  contact  with 
the  decidual  tissue.  Where  the  latter  is  in  a  condition  of  hyaline 
degeneration,  the  line  of  demarcation  may  be  readily  made  out; 
where  the  degeneration  is  also  present  in  the  villus,  it  is  very  dif- 
ficult to  distinguish  fetal  from  maternal  tissue.  Owing  to  the 
thinness  of  the  serotina  in  parts  the  attached  villi  may  be  very 
close  to  the  muscular  part  of  the  wall.  Occasionally  the  decidua 
is  entirely  absent,  the  villi  lying  in  contact  with  the  muscle. 

Non=placental  Part  of  the  Chorion. — In  the  earliest  specimens 
of  the  pregnant  uterus  no  distinction  can  be  established  between 
the  villi  attached  to  the  serotina  and  those  attached  to  the  reflexa, 


Fig.  37. — Section  through  part  of  decidua  serotina  and  placenta.  Sixth  week  of 
pregnancy.  X  60.  a.  Compact  layer  of  serotina  ;  b,  b,  layer  of  syncytium  on  surface 
of  serotina;  c,  villus;  d,  maternal  blood  in  intervillous  spaces. 


either  in  regard  to  number,  size,  shape,  or  minute  structure.  The 
description  already  given  of  the  early  placental  portion  will  also 
serve  for  that  of  the  non-placental  portion.  The  first  change  by 
which  a  distinction  can  be  established  usually  begins  before  the 
end  of  the  first  month  of  gestation.  It  is  a  growth  of  villi  in 
relation  to  the  serotina  more  marked  than  in  relation  to  the 
reflexa.  In  the  sixth  week  the  chorionic  membrane  has  the  same 
appearance  in  all  parts,  the  distance  between  it  and  the  reflexa 
varying  in  size  in  different  specimens.  Toward  the  outer  polar 
portion  of  the  reflexa  this  space  diminishes  in  width,  the  chorionic 
membrane  lying  in  closer  relationship  with  the  reflexa,  being  to  a 
great  extent  in  contact  with  it  or  separated  only  by  a  few  villi. 
The  villi  vary  considerably.  Near  the  serotina  they  are  most 
numerous  and  similar  to  those  of  the  chorion  frondosum  ;  further 


54 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


out  they  are  less  branched  and  possess  fewer  epithelial  buds  and 
are  poorly  vascularized,  some,  indeed,  containing  no  capillaries ; 
in  many  the  connective  tissue  has  a  hyaline  appearance.  Near 
the  serotina  many  villi  are  attached  to  the  reflexa  by  marked  pro- 
liferation of  the  Langhans  layer ;  elsewhers  it  is  found  to  a  much 
less  extent.  By  this  time,  as  already  has  been  pointed  out,  con- 
siderable hyaline  or  fibrinous  degeneration  may  be  found  in  the 
reflexa,  and  in  some  parts  the  ends  of  the  villi  are  also  degen- 
erated. As  pregnancy  advances  the  reflexa  thins  and  gradually 
disappears,  and  the  chorionic  membrane  may  lie  in  many  places 
directly  in  contact  with  the  vera,  the  line  of  union  varying  in 
different  parts,  being  regular  in  some  areas  and  uneven  in  others. 
The  original  reflexal  villi  have  degenerated,  their  superficial  epi- 


•  •  -  •:    .    -  ••  •      4.    k  _        ..  «      vT  - 


Fig.  38. — Section  from  sixth-week  pregnant  uterus.  X  80.  a,  Compact  layer  of 
serotina  ;  b,  gland  ;  c.  villus  attached  to  surface  of  serotina  by  syncytial  layer  ;  d,  stalk 
of  syncytium  extending  into  serotina;  e,  syncytium  on  surface  of  serotina  continuous 
with  covering  of  villus. 

thelium  having  become  destroyed,  their  connective  tissue  hav- 
ing undergone  hyaline  degeneration.  They  become  compressed 
between  the  chorionic  membrane  and  the  decidua ;  by  the 
sixth  month  these  two  tissues  are  in  parts  adherent.  The  cho- 
rionic connective  tissue  is  fibrillated,  the  nuclei  being  elongated 
parallel  to  the  surface.  The  chorionic  epithelium  which  forms  the 
means  of  attachment  to  the  decidua  is  usually  a  well-marked 
layer,  rarely  more  than  two  rows  of  cells  in  thickness.  Occa- 
sionally, at  this  time,  portions  of  the  original  reflexa  which  have 
not  disappeared  may  still  be  found  between  the  chorionic  mem- 
brane and  the  vera.  At  full  time  the  chorionic  connective  tissue 
is  generally  dense  in  structure,  the  epithefial  layer  being  usually 
distinct  and  thickest  close  to  the  placenta.  Many  are  vacuolated 
and  present  other  signs  of  degeneration. 


PLACENTA  TION. 


55 


Relation  of  the  Vessels  of  the  Mucosa  to  the  Inter- 
villous Circulation. — It  has  been  clearly  demonstrated  by 
Peters's  specimen  that  as  the  ovum  breaks  through  the  surface 
of  the  mucosa  and  becomes  embedded  in  the  compacta  there  may 
be  a  small  extravasation  of  maternal  blood  around  the  ovum.  In 
his  case  it  formed  a  clot  over  the  outer  polar  portion  at  the  site 
of  entrance  through  the  surface  mucosa. 

Peters  supposes  that  this  blood  furnishes  nourishment  to  the 
ovum.  Whether  this  extravasation  always  occurs  can  only  be 
settled  by  the  examination  of  other  early  specimens.  It  may 
only  be  accidental  in  Peters's  case. 


/ 


a, 


)c 


Fig.  39. — Section  from  full-time  gestation.  X  80.  a,  Compact  layer  of  serotina; 
i,  spongy  layer  ;  c,  portion  of  muscular  wall ;  d,  decidual  cells  ;  e,  remains  of  syncytium 
on  surface  of  decidua ;  /,  villi. 

His  sections  very  clearly  establish,  however,  what  my  previous 
work  has  led  me  to  conjecture  as  to  the  earliest  stage  in  the 
establishment  of  a  relationship  between  the  chorion  and  maternal 
blood.  This  I  have  already  described  in  detail.  The  great  mul- 
tiplication of  the  chorionic  epiblast  to  form  a  trophoblast  layer  is 
accompanied  by  the  formation  of  lacunae  in  the  latter,  into  which 
maternal  blood  finds  its  way. 

That  the  walls  of  the  maternal  sinuses  are  perforated  by  the 
phagocytic  action  of  the  trophoblast  can  scarcely  be  doubted. 

The  lacunae  in  the  trophoblast  are  the  beginnings  of  the  inter- 
villous spaces  of  the  well-formed  placenta.    Owing  to  the  gradual 


56 


ANATOMY  AND   PHYSIOLOGY   OF  PREGNANCY. 


Fig.  40. — Section  through  inner  part  of  uterine  wall  in  the  non-placental  area. 
Sixth  month  of  gestation.  X  80.  a.  Portion  of  muscular  wall  ;  b,  decidua  vera ;  c, 
decidual  cells  ;  </,  gland  space  ;  <?,  chorionic  epithelium  ;  f,  chorionic  connective  tissue  ; 
g,  amniotic  epithelium  ;  h,  amniotic  connective  tissue. 

establishment  of  communication  between  them,  maternal  blood 
very  early  circulates  around  the  whole  chorionic  surface  of  the 
ovum. 

As  pregnancy  advances  this  circulation  gradually  becomes 
limited  to  the  chorion  frondosum,  or  that  part  which  enters  into 


Fig.  41. — Section  through  uterine  wall  and  attached  placenta  (Wagner):  u.  Uterine 
wall  rendered  spongy  by  greatly  developed  uterine  sinuses  {us) ;  va,  branches  of  uterine 
artery;  ds,  decidua  serotina;  j,  line  of  separation  ;  /)!i,  fetal  portion  of  placenta,  con- 
sisting of  a  mass  of  vascular  fetal  villi  {v. v. v.),  surrounded  by  the  maternal  blood 
sinuses;  am,  amnion  covering  free  internal  surface  of  placenta. 


PLA  CENTA  TION. 


57 


the  formation  of  the  placenta.  Occasionally,  however,  a  small  or 
large  portion  of  the  chorion  laeve  may  remain,  developing  con- 
tinuously with  the  frondosum,  and  the  maternal  blood  may  circu- 
late among  its  villi,  which  thus  form  a  reflexal  placenta. 

In  the  permanent  condition  the  villi  are  attached  mainly  by 
their  ends  to  the  surface  of  the  decidua.  They  do  not  force  their 
way  through  the  walls  of  the  maternal  sinuses  so  as  to  hang 
naked  in  them,  nor  do  they  become  covered  with  an  investment 
of  maternal  endothelium.  These  old  views  must  be  entirely 
abandoned.     It  is  very  exceptional  to  find  a  villus  hanging  into 


'  "7     "J 

/  '.  '  . 

-'  '  ,  // 

if.: 

■■  ■-■i 

ft:    •      ' 

.* 

---r>^^^;''. 

I      !•.-'< 

i      1    '        '  ''    / 

^  *  ' 

\ '" 

"•''■---  ,  ('     , ' 

1     *          '   1    ■     'v     ^ 

~  \  \'    1 

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■J            '      ■    ^J.     ' 

*  *  ^ 

l.    - .'_ 

■  ',.'''     t'^^'V  '■    ' 

■''Mr.'^-' 

^  . 

;  /      1     ■  '      •'  1 

;            1 

/     *       ~"   V             ~  ' 

1) 

■ .    .  /     ,■  /       <- 1 

1    '/     |!     •   '', 

*. 

'       '/*'i'    • 

'-->/' 

■^  ''^'i\ 

'  it  1 '  ■.     Ml''" 

\  •  'U '  J 

i::^^^M 

■;      '-  >s^'/  'h 

'  ,  1    ■'   '-  / 

4     (     *  \    *"-            '        f 

V  "^ 

i/.       ~ 

1 

V":n;    ;.- 

vl 

\  \\'  i 

:         1 

\^\  -■     - 

"x;  .-::• 

...  - 

Fig.  42. — Villus-stem  from  full-time  placenta.  The  epithelium  varies  in  thickness. 
In  parts  it  is  absent.  The  connective  tissue  is  dense,  especially  a'round  some  of  the 
vessels.     X  80. 


the  open  mouth  of  a  sinus  at  the  surface  of  the  decidua  or 
attached  to  its  walls. 

Neither  is  there  any  extension  of  the  endothelium  of  the 
maternal  sinuses  outward,  forming  a  covering  for  the  villi ;  this 
old  view  has  been  based  on  an  incorrect  interpretation  of  the 
appearances  seen  in  sections.  Recent  careful  histologic  methods 
have  shown  that  the  covering  of  the  villi,  long  termed  "  maternal 
endothelium,"  is  really  "  fetal  epiblast."  In  advanced  pregnancy 
the  latter  may  be  thinned  in  parts,  resembling  the  former. 

The  condition  of  the  maternal  vessels  which  communicate  with 


58  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 

the  intervillous  spaces  must  also  be  noted.  It  is  very  evident 
that,  as  the  maternal  blood  circulates  among  the  villi,  giving  up 
its  oxygen  and  nourishment  to  the  fetal  blood  in  the  villi,  there 
must  be  openings  in  the  serotina  through  which  the  current  flows 
toward  the  villi,  and  others  through  which  it  flows  from  the  inter- 
villous spaces  into  the  maternal  venous  system. 

Much  has  been  written  as  to  the  nature  of  the  serotinal  vessels 
and  their  relationship  to  the  intervillous  space.  Attention  may  be 
particularly  directed  to  the  work  of  Waldeyer,  Turner,  and  Bumm. 
It  is  usually  stated  that  both  arteries  and  veins  open  into  the  inter- 
villous spaces.  I  object  to  the  use  of  these  words,  and  would  sub- 
stitute "  afferent  "  and  "  efferent  "  vessels  instead. 

There  can  be  no  doubt  that  in  normal  cases  it  is  rare  to  find  a 
vessel  worthy  of  the  name  of  arter}-  or  vein  in  the  superficial  part 
of  the  mucosa.  They  are  mainly  capillaries,  having  lost  their  mus- 
cular and  elastic  coats  deeper  down.  One  does  find  a  few  small 
vessels,  to  which  the  term  "  arteriole"  may  be  applied,  consisting 
of  a  lining  of  endothelium  surrounded  by  one  or  two  layers  of 
somewhat  flattened  connective-tissue  cells.  These  conditions  are 
found  in  the  non-pregnant  uterus  as  well  as  in  early  pregnancy. 
Block,  who  has  particularly  studied  the  vessels  of  the  mucosa  in 
eight  specimens  of  pregnant  uterus,  is  of  exactly  the  same  opinion 
as  myself  on  this  point. 

One  of  the  earliest  changes  in  pregnancy  is  the  dilatation  of 
capillaries  in  the  superficial  layers  of  the  decidua,  giving  rise  to 
large  sinuses.  The  arterioles  and  venules  which  communicate 
with  these  are  also  somewhat  increased  in  size.  Microscopically 
it  is  impossible  to  distinguish  man}'  of  these  arterioles  and  venules 
from  one  another,  and  I  am  at  a  loss  to  know  how  certain  observers 
hav^e  so  confidently  figured  vessels  in  their  drawings  as  one  or  the 
other. 

Neither  can  any  support  be  given  to  those  who  describe  a  par- 
ticular and  definite  arrangement  of  the  afferent  and  efferent  vessels. 
Thus,  Bumm,  in  a  recent  paper,  gives  a  diagram  representing  the 
afferent  vessels- (called  "  arteries  "  by  him)  opening  into  the  inter- 
villous spaces  on  the  sides  of  the  outward  prolongations  of  the 
decidua  (called  by  him  "  intercotyledonary  septa  "),  and  the  effer- 
ent vessels  (named  "  veins  "  by  him)  opening  from  the  surface  of 
the  decidua  between  these  prolongations.  His  beautifully  figured 
artery  coiling  on  a  decidual  hillock  and  sending  jets  of  red  paint 
outward  among  the  villi  must  be  regarded  only  as  a  pretty  fanc}'. 

No  such  systematic  and  orderly  arrangement  can  be  found. 
Afferent  as  well  as  efferent  vessels  open  indiscriminately  on  the 
decidual  surface  between  the  decidual  elevations  as  well  as  on 
them,  as  Farre  long  ago  pointed  out ;  and  for  the  most  part  the 
openings  occur  between  those  narrow  prolongations  of  the  decidua 
to  which  the  term  "  septa  "  has  been  applied.     Kolliker,  indeed. 


PLACENTATION. 


59 


could  find  no  arterial  openings  in  these  septa.  They  are  generally 
poorly  vascularized.  Indeed,  if  the  afferent  blood  alone  proceeded 
from  them,  the  villi  would  be  but  poorly  nourished. 

The  vessels  by  which  blood  enters  and  leaves  the  intervillous 
spaces  are  almost  entirely  the  large  sinuses — dilated  capillaries 
of  the  compact  layer  of  the  serotina.  The  opening  of  communi- 
cation will  direct  an  afferent  or  efferent  current,  probably,  according 
to  whether  it  is  nearer  the  arterial  or  venous  end  of  the  sinus.  It 
is  very  rare  for  a  small  arteriole  or  venule  to  open  directly  into 
the  intervillous  space.  As  to  the  nurriber  of  openings  in  a  full- 
time  specimen,  we  have  no  accurate  information.  Attempts  have 
been  made  to  estimate  them.  According  to  Waldeyer,  they  are 
most  numerous  in  the  central  portion  of  the  area  serotina. 

As  to  the  physics  of  the  intervillous  circulation,  it  is  very 
evident  that  the  windings  of  the  small  arterial  vessels  through 


-■^■' 

Fig.  43. — Section  from  full-time  pregnant  uterus.     X  25.    a,  Portion  of  muscular  wall; 
b,  decidua  serotina  ;  ;:,  villi. 

the  muscular  part  of  the  uterine  wall  and  the  deeper  part  of  the 
mucosa  must  be  associated  with  a  diminution  of  the  force  with 
which  the  blood  is  poured  into  the  intervillous  space.  The  dila- 
tation of  capillaries  into  large  sinuses  must  also  assist  in  diminish- 
ing the  force  of  the  current.  If  the  arteries  were  to  run  a  straight 
course  and  to  open  directly  into  the  intervillous  spaces  without  the 
interposition  of  blood-sinuses,  the  jets  of  blood  would  probably  be 
a  source  of  danger  to  the  villi,  tearing  them  across  or  separating 
them  from  their  attachments. 

The  condition  of  the  veins  in  the  mucosa  is  such  as  to  favor 
the  removal  of  the  deoxygenated  blood  as  rapidly  as  possible ; 
they  have  not  the  tortuosity  of  the  arterioles,  but  run  a  more 
direct  course. 

In  conclusion,  it  may  be  noted  that  the  intervillous  circulation 
is  so  conditioned  as  to  be  largely  independent  of  sudden  changes 
in  the  maternal  vascular  system.    It  is  probably  not  a  swift-flowing. 


6o 


JA'JTOMV  AXD   PHYSIOLOGY   OF  PREGNANCY. 


pulsating  stream,  but  a  steady-moving  mass  of  blood.  Evidently 
the  least  motion  will  be  at  the  parts  most  distant  from  the  open- 
ings— /.  c,  the  surface  of  the  chorionic  membrane.  Variations  in 
resistance  will  be  found  also  next  to  the  decidual  surface,  according 
to  the  number  and  position  of  the  openings  of  the  maternal  sinuses 
in  it. 

Amnion. — At  what  period  in  the  human  ovum  the  folds 
of  the  extra-embiyonic  somatopleure  develop,  giving  rise  to  the 
amnion,  we  are  uncertain.  Peters  states  that  the  amniotic  cavity 
was  completely  closed  in  his  early  specimen,  being  lined  with  a 


Mes^ 


E.Sch.   V^  ^^ 


Mis. 


Ent 


tei£l;-^t 


««0 


Fig.  44. — .Section  tlirough  embryonic  region  of  ovum.  First  week  of  pregnancy 
(H.  Peters):  E.Sch.,  Embryonic  epib'last ;  E?it.,  embryonic  hypoblast;  Afes.,  embryonic 
mesoblast ;  D.S.,  umbilical  vesicle;  Ekf.,  chorionic  epiblast ;  Sp.,  fold  in  exocelom  ; 
A.H.,  amniotic  cavitv  lined  by  a  single  layer  of  flattened  cells,  which  are  in  striking 
contrast  with  the  layer  of  cylindric  cells  of  the  embryonic  epiblast. 


la\"er  of  very  flattened  cells  opposite  the  embryo  and  with  cylin- 
dric cells  next  to  it.  Outside  was  a  layer  of  mesoblast,  consisting 
of  several  thicknesses  of  cells. 

In  Spec's  early  case  of  the  second  week  the  epiblastic  layer 
consisted  of  a  single  layer  of  flattened  cells,  the  mesoblast  con- 
sisting of  a  single  layer  of  cells. 

During  the  third  and  fourth  weeks  the  epiblastic  layer  is  not 
unlike  an  endothelium,  so  flattened  are  the  cells  composing  it. 
The  nuclei  are  round  or  oval  and  placed  at  varying  distances 
from  one  another.  The  mesoblastic  tissue  varies  in  thickness, 
being  composed  of  an  outer  layer  very  similar  in  appearance  to 


PL  A  CENT  A  TION.  6 1 

the  epiblastic  layer  and  termed  the  mesothehum,  and  an  inner 
layer  lying  next  the  epiblast,  composed  of  a  homogeneous,  faintl}' 
staining  material,  finely  fibrillated,  in  which  very  few  cells  can  be 
seen. 

By  the  fourth  month  the  epithelial  cells  have  become  more 
numerous  and  are  less  flattened  than  previously,  for  the  most 
part  having  a  cubical  shape ;  in  some  parts  being  columnar.  The 
connective  tissue  still  presents  a  dense,  homogeneous  appearance 
next  the  epiblast,  being  looser  next  the  chorionic  mesoblast ;  it  is 
usually  connected  with  the  latter  by  loose  strands. 

At  full  time  the  epithelium  is  mainly  cubical,  though  in  some 
places  it  is  columnar.  On  surface  view  the  cells  appear  irregu- 
larly rounded  or  polygonal  in  outline.  Their  edges  appear  to 
form  irregular  projections,  which  seem  to  blend,  forming  bridges 
between  adjacent  cells.  Stomata  have  been  described  among  the 
ceils  by  various  authors,  but  others  deny  that  they  exist. 

The  connective  tissue  is  loosely  connected  with  that  of  the 
chorion  in  most  parts,  the  connecting  strands  being  termed  the 
subamniotic  layer  by  Barbour ;  here  and  there  firm  union  exists, 
so  that  no  distinction  between  them  can  be  made  out. 

Shed  Placenta. — The  shed  placenta  is  smaller  in  area 
and  thicker  than  it  is  in  situ  before  labor.  This  is  due  to  the 
compression  of  the  organ  during  labor,  maternal  blood  being 
forced  to  a  large  extent  out  of  the  intervillous  spaces,  the  volume 
of  fetal  blood  in  the  villi  also  being  reduced. 

As  it  appears  at  the  end  of  the  third  stage  it  is  best  described 
as  discoidal.  A  considerable  range  of  variations  are  found  as 
regards  its  size,  shape,  color,  and  consistence. 

On  the  average,  in  the  case  of  single  pregnancies,  it  is  some- 
what rounded,  and  measures  crosswise  about  seven  inches.  In 
its  central  portion  the  thickness  is,  on  the  average,  one  inch.  It 
usually  thins  gradually  toward  the  edge.  Sometimes  the  thick- 
ness is  fairly  uniform  until  near  the  edge,  when  it  suddenly  dimin- 
ishes. In  some  cases  the  thickness  varies  considerably  in  different 
portions.  Its  outline  is  often  oval,  but  is  sometimes  ovoid,  reni- 
form,  crescentic,  or  lobed. 

One  or  more  detached  portions  may  occasionally  be  found — 
"  placenta  succenturiata."  The  separated  mass  may  be  related  to 
maternal  blood,  just  as  is  the  main  part  of  the  placenta.  Rarely 
the  detached  portion  may  be  as  large  as  that  to  which  the  cord  is 
attached,  explaining  what  is  sometimes  described  as  a  double 
placenta  with  a  single  fetus.  In  such  a  condition  the  cord  may 
end  in  the  membranes  joining  the  two  parts  of  the  placenta,  its 
vessels  going  to  each. 

Sometimes  the  villi  of  the  small  separated  portion  are  func- 
tionless,  the  mass  being  termed  "  placenta  spuria." 

In    some    cases    the    separated    portion    is    derived    from    an 


62 


ANATOMY  AND  PHYSIOLOGY  OF  PREGNANCY. 


abnormal  development  of  a  circumscribed  area  of  the  chorion 
Iseve.  Very  rarely  the  placenta  may  extend  ring-like  around  the 
uterus,  being  thus  similar  to  the  condition  found  in  some  lower 
mammals.     When  a  gap  exists  in  its  substance,  owing  to  scanti- 


\ 


\ 


Fig.  45. — Uterine  surface  of  placenta  immediately  after  delivery  (reduced). 


ness  or  absence  of  villi,  the  condition  is  termed  "  placenta  fenes- 
trata." 

The  consistence  of  the  placenta  is  variable.  It  may  be  quite 
firm  or  very  soft  and  plastic.  Its  weight  varies  a  good  deal ; 
ordinarily  from  twelve  to  twenty  ounces. 

The  uterine  surface  varies  in  appearance.  It  is  usually  dark 
red,  but  it  may  be  quite  pale.     Ordinarily  it  consists  of  a  number 


Plate  4, 


Anomalies  of  the  Placenta:  i,  Placenta  with  irregular  lobes  (Auvard)  ;  2,  placenta  in 
two  unequal  lobes  (Auvard)  ;  3,  irregular  placenta  (Auvard)  ;  4,  small  accessory  placenta 
( Ribemont- Lepage)  ;  5,  placenta  succenluriata  (Riijemont-Lepage)  ;  6,  "battledore" 
placenta,  oval  f  Auvard)  ;  7,  placenta  with  velamentous  attachment  of  cord  (Ribemont- 
Lepage)  ;   8,  placenta  with  two  equal  lobes  ( Ribemont- Lepage). 


PI.  A  CENTA  TION.  63 

of  irregularly  rounded  convex  areas,  with  fissures  running  be- 
tween them.  These  areas  are  generally  termed  cotyledons.  It 
is,  however,  very  rare  that  any  definite  cotyledonary  arrangement 
exists.  The  fissures  are  usually  shallow,  extending  only  a  short 
distance  into  the  substance  of  the  placenta.  Occasionally  they 
may  divide  half  or  more  of  its  thickness.  They  vary  greatly 
in  number,  and  consequently  the  areas  between  them  vary  greatly 
in  size. 

This  surface  is  usually  said  to  be  rough  and  shaggy.  This  is, 
however,  an  inaccurate  description.  A  very  large  portion  of  it  is 
fairly  smooth.  As  I  have  already  pointed  out,  in  speaking  of  the 
separation  plane  of  the  ovum,  the  maternal  surface  of  the  shed 
placenta  usually  represents  a  plane  passing  through  the  compact 
layer  of  the  decidua  serotina.  This  is  not  rough  and  shaggy. 
The  latter  description  applies  to  those  areas  which  represent  a 
plane  passing  through  the  spongy  layer  of  the  decidua.  But 
ordinarily  it  is  only  here  and  there  that  this  part  is  torn  through. 
The  surface  is  also  shaggy  when,  as  not  infrequently  happens,  the 
ends  of  the  villi  are  exposed,  no  decidual  tissue  having  been 
removed. 

An  exact  idea  of  the  surface  can  best  be  obtained  b}'  placing 
the  placenta  in  a  basin  of  water  and  examining  it  with  a  hand- 
lens.  The  distinction  between  the  shaggy  and  smooth  portions 
can  thus  easily  be  made  out. 

The  fetal  surface  is  covered  with  the  amnion,  which  is  smooth 
and  shining.  Through  it  can  be  seen  the  chorionic  membrane, 
from  the  lower  surface  of  which  the  villi  extend.  The  chorion  has 
a  mottled  appearance,  usually  a  mixture  of  purple,  gray,  and 
yellow  areas,  which  vary  greatly  in  size,  ordinarily,  from  the  thick- 
ness of  a  pin-head  to  that  of  a  pea ;  in  some  cases  they  are  con- 
siderably larger. 

The  amnion  may  easily  be  stripped  from  the  surface  as  far  as 
the  insertion  of  the  cord. 

The  umbilical  cord  usually  enters  the  fetal  surface  of  the  pla- 
centa near  the  center.  It  may,  however,  be  inserted  at  any  point 
between  the  center  and  the  margin.  In  some  cases  the  cord  is 
inserted  into  the  membranes — the  velamentous  insertion. 

From  the  cord  the  branches  of  the  umbilical  vein  and  arteries 
spread  in  the  superficial  part  of  the  chorion  under  the  amnion  to 
all  parts  of  the  placenta,  being  very  distinctly  recognized.  In 
some  cases  very  few  of  the  vessels  stand  out  prominently  on  the 
surface.  The  veins  are  beneath  the  level  of  the  arteries,  and  are 
larger  in  caliber.  There  are  no  anastomoses  between  the  branches 
of  either  of  these  sets  of  vessels  outside  of  the  cord.  Often  the 
two  arteries  are  connected  by  a  short  branch  about  half  an  inch 
above  the  placental  end  of  the  cord.  Most  of  the  vessels  can 
be  traced  in  their  various  divisions  until  they  disappear  as  fine 


64 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


branches  to  supply  the  vilh  ;  sometimes  a  large  branch  disappears 
abruptly,  its  ramifications  not  being  visible.  Great  variations  are 
noticed  as  regards  the  course  of  the  branches.  Minot  states  that 
the  more  eccentric  the  insertion  of  the  cord  the  more  symmet- 
rically are  the  vessels  distributed  ;  the  nearer  the  center  the  less 
their  symmetr}\ 

Occa.sionally  remains  of  the  umbilical  duct  and  vesicle  maybe 
noticed  under  the  amnion,  close  to  the  cord.  The  former  is  a 
minute  sac  ;  the  latter  a  thread-like  stalk.  Very  rarely  these  may 
be  accompanied  with  unobliterated  omphalomesenteric  vessels. 


Fig.  46. — Placenta  at  full  term,  showing  superficial  distribution  of  blood-vessels  (Minot). 

At  the  edge  of  the  placenta  the  amnion,  chorion,  and  decidual 
layers  extend  outward,  forming  the  so-called  "  membranes." 

Occasionally  the  place  of  transition  is  not  the  edge  of  the  pla- 
centa, but  a  ring  around  the  fetal  surface  of  the  organ,  internal  to 
the  edge. 

A  good  idea  of  the  general  plan  of  the  placenta  may  be 
obtained  from  the  study  of  transverse  sections  across  it.  On 
the  fetal  side  are  the  amniotic  and  chorionic  membranes.  On  the 
maternal  side  is  a  very  thin  layer  of  decidual  tissue,  which  may 
be  wanting  in  places.  These  meet  and  are  in  close  apposition  at 
the  placental  edge ;  here  the  decidual  layer  may  often  spread  for 
a  short  distance  on  the  under  surface  of  the  chorionic  membrane. 

Between  the  decidual  and  chorionic  layers  there  is  thus  a  large 


PLA  CENT  A  no  A .  6  5 

area,  forming  the  main  thickness  of  the  placenta.  This  area  is  a 
space  which  is  almost  entirely  occupied  with  projections  of  the 
chorion,  forming  the  villus-stems  and  villi,  which  vary  in  size, 
shape,  and  structure.  Many  of  the  large  stems  are  attached  to 
the  decidual  layer ;  the  great  majority  of  the  small  villi,  however, 
hang  free  like  the  branches  of  a  tree.  Surrounding  the  villi  is 
maternal  blood,  which  gives  the  dark-red  color  to  the  placenta. 
Ordinarily  the  intervals  between  the  villi  in  which  the  maternal 
blood  is  found  are  termed  "  intervillous  .spaces,"  but  it  must  be 
clearly  understood  that  these  spaces  are  in  free  communication. 
The  expression  "  intervillous  space  "  is,  therefore,  more  accurate. 
In  the  angle  at  the  edge  of  the  placenta  very  few  villi  may  exist 
in  some  parts,  so  that  the  appearance  of  a  sinus  is  produced,  and, 
indeed,  it  has  been  termed  the  circular  simis.  No  special  name 
should  be  given  to  it,  however.  It  is  merely  the  marginal  portion 
of  the  intervillous  space,  and  never  extends  as  a  direct  sinus 
around  the  placenta,  but  is  interrupted  at  irregular  intervals  by  a 
well-marked  development  of  villi. 

Besides  the  villus-stems  and  villi  sections  of  buds  and  irreg- 
ular masses  of  syncytium  growing  from  the  chorionic  membrane 
and  villi  are  noticed.  In  many  parts,  where  the  free  ends  have 
been  divided,  the  appearance  is  presented  of  masses  lying  free  in 
the  maternal  blood.  Here  and  there  several  villi  closely  pressed 
together  are  cut  across.  Some  of  these  are  embedded  in  fibrin, 
others  are  not.  These  are  different  forms  of  the  Zcllknotcn,  which 
I  have  previously  described.  Portions  of  fibrin  are  also  found 
on  the  surface  of  a  number  of  villi.  Besides  these  structures  are 
noticed  elevations  of  the  decidual  layer  forming  the  maternal 
surface,  and  generally  termed  decidual  septa.  They  are  directed 
perpendicularly  or  obliquely  toward  the  fetal  surface  of  the  pla- 
centa, and  are  for  the  most  part  very  short ;  they  rarely  extend 
into  the  intervillous  space  for  any  considerable  distance.  Some- 
times, near  the  edge  of  the  placenta,  they  may  nearly  reach  the 
chorionic  membrane. 

Villi  are  attached  to  them  as  well  as  to  the  general  surface  of 
the  decidua.  Leopold  and  others  consider  that  these  are  of  great 
structural  importance,  and  suppose  that  fixation  villi  are  chiefly 
attached  to  them.  Extensive  study  of  the  placenta  proves  this 
view  to  be  wrong.  These  decidual  projections  vary  greatly  in 
their  development,  being  usually  short,  and  often  very  scanty. 
They  have  no  special  significance  in  relation  to  the  attachment 
of  the  villi. 

Often  sections  across  free  ends  of  such  projections  may  be 
noticed,  giving  the  appearance  of  portions  of  decidual  tissue  lying 
free  in  the  maternal  blood  of  the  intervillous  space.  Occasion- 
ally such  a  section  may  include  a  number  of  villi  attached  to  the 
decidual  tissue  or  closely  pressed  against  it ;  varying  quantities 

.5 


66  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 

of  fibrin  may  also  be  found  between  or  around  these  villi.  Such 
masses  form  other  varieties  of  the  Zcllknotcii. 

The  quantity  of  maternal  blood  in  the  intervillous  space 
varies  greatly.  Where  it  is  small  the  villi  are  closely  massed 
together. 

Of  all  the  tissues  above  noted  the  fetal  elements  form  by  far 
the  greater  portion.  This  can  be  clearly  demonstrated  if  the 
chorionic  vessels  be  injected  with  a  carmin-gelatin  solution 
through  the  umbilical  arteries,  the  decidual  layer  being  afterward 
carefulh'  removed  by  dissection,  and  the  maternal  blood  washed 
out  of  the  intervillous  space.  When  the  mass  is  placed  in  water 
the  thickness  of  the  placenta  is  seen  to  consist  of  a  beautiful  fron- 
dose  arrangement  of  the  injected  villi. 

In  such  a  preparation  the  fetal  vessels  may  be  distinct!}'  traced. 
The  large  veins  and  arteries  ramif.-  in  the  chorionic  membrane, 
the  latter  being  more  branched  than  the  former.  They  dip  down 
into  the  villus-stems,  dividing  mainly  dichotomously  and  extend- 
ing into  their  various  branches.  In  the  small  villi  capillaries  only 
are  found  ;  in  several  the  latter  do  not  alwa\-s  extend  throughout 
the  whole  length.  In  short  ones  there  is  usually  only  a  single 
loop ;  in  larger  ones  a  tortuous  arrangement  of  the  \'essels,  form- 
ing a  number  of  loops,  between  which  an  anastomosis  may  exist. 

I  have  already  pointed  out  that  the  vessels  vary  in  size  in 
different  specimens.  Ordinarily  the  capillaries  are  small,  but  they 
may  sometimes  be  dilated,  allowing  six  or  more  blood-corpuscles 
to  lie  side  by  side.  OccasionalU^  a  capillar}^  may  be  small  at  one 
point  and  wide  at  another. 

Placental  Infarcts. — Very  frequenth-  the  placenta  presents 
areas  of  various  sizes,  shapes,  and  colors,  which  are  generally 
termed  infarcts.  Wliitridge  Williams  has  recenth'  classified  them 
as  follows : 

1.  Small  whitish  or  yellowish  fibrous-like  areas,  a  {g.\\  milli- 
meters in  thickness,  sharply  marked  off  from  the  surrounding 
placental  tissue. 

2.  Wxdge-shaped  or  irregularh-  rounded  dull-white  areas,  of 
a  striated  fibrinous  appearance. 

3.  Large  portions  of  placenta  showing  this  change. 

4.  A  }^ellowish-white  rim,  varying  in  width  and  thickness, 
extending  around  the  margin  of  the  placenta  on  the  fetal  side 
under  the  amnion,  forming  a  complete  or  partial  ring.  This 
condition  is  often  termed  "'placenta  uiaj'ginatay 

In  some  cases  this  ring  is  situated  more  than  half  an  inch 
internal  to  the  edge. 

5.  Rarely  a  pinkish  or  brickdust-colored  mass,  of  small  or 
large  size,  found  mainly  near  the  maternal  surface,  but  sometimes 
occupying  the  w^hole  thickness  of  the  placenta.  These  are  known 
as  "  red  infarcts!' 


PL  A  CENTA  riON.  6/ 

6.  Very  rarely  there  are  scattered  through  the  placenta  red  or 
black  areas,  of  various  sizes,  consisting  of  blood  surrounded  by  a 
fibrous-like  substance.  These  are  termed  by  some  "  red  infarcts^' 
by  others  "  apoplexies."  Pinard  has  named  the  appearance  ''pla- 
centa truffe."  Williams  points  out  that  these  are  quite  distinct 
in  nature  from  the  above-mentioned  red  infarcts. 

Very  many  views  have  been  advanced  as  to  the  nature  of  these 
infarcts.  Williams  has  fully  tabulated  them,  but  it  is  beyond  the 
scope  of  this  work  to  refer  to  them  in  detail.  It  is  here  only 
necessary  to  consider  their  relationship  to  the  changes  normally 
found  in  placental  growth  and  development.  Do  they  occur  in 
healthy  conditions  or  are  they  an  indication  of  maternal  or  fetal 
disease  ?  In  the  present  state  of  our  knowledge  it  is  impossible 
to  answer  this  question  accurately. 

Williams  noticed  infarcts  measuring  at  least  i  cm.  in  diameter 
in  315  out  of  500  placenta.  Smaller  ones,  many  just  visible  to 
the  naked  eye,  were  observed  in  the  great  majority  of  placentae, 
while  microscopic  examination  revealed  early  stages  of  infarct 
formation  in  every  full-time  placenta  examined  by  him. 

He  regards  this  condition,  in  a  moderate  degree  of  develop- 
ment, as  not  pathologic,  and  exerting  no  influence  upon  mother 
or  fetus.  It  is  to  be  regarded  as  a  sign  of  senile  change  in  the 
placenta,  as  Avas  first  suggested  by  Druitt  years  ago. 

My  own  observations  are  in  harmony  with  those  of  Williams, 
not  only  as  regards  the  frequency  and  significance  of  infarcts,  but 
as  regards  their  mode  of  formation. 

The  chief  cause  of  the  process  is  the  thickening  of  the  intima 
in  vessels  of  various  vilH,  especially  in  those  of  medium  size.  Of 
less  importance  in  diminishing  the  lumen  of  the  vessels  is  thick- 
ening of  the  connective  tissue  around  them.  These  vascular 
changes,  already  fully  described  by  me,  have  been  noted  by  a 
number  of  previous  observers,  the  most  prominent  of  whom  was 
Ackermann. 

The  first  result  of  obliteration  of  the  lumen,  according  to 
Williams,  is  coagulation-necrosis  beneath  the  syncytium,  with 
subsequent  formation  of  canalized  fibrin. 

In  my  description  of  full-term  villi  I  have  pointed  out  the 
frequency  of  fibrinous  material  on  the  surface  of  the  villi,  with 
remains  of  the  syncytial  layer  external  to  it,  or  in  some  parts 
none  whatever. 

This  fibrin  probably  results  from  changes  in  the  Langhans 
layer  of  epithelial  cells  and  the  underlying  stroma.  That  the 
Langhans  cells  do  largely  undergo  this  transformation  normally, 
as  has  been  mainly  demonstrated  by  Nitabuch  and  Eberhardt,  my 
sections  clearly  show. 

The  syncytium  may  undergo  the  same  change,  but  always 
later,  as  is  best  demonstrated  in  the  formation  of  the  infarct.     Its 


68  ANATOMY  AXD   PHYSIOLOGY  OF  PREGNANCY. 

presentation  is  probabh^  due  to  its  contact  with  the  maternal 
blood,  from  which  it  may  be  nourished.  As  Peters  has  pointed 
out,  the  syncytial  layer  acts  as  a  kind  of  endothelium  for  the 
intervillous  blood,  serving  an  important  function  in  transmitting 
necessary  elements  to  the  fetal  blood-stream.  It  also  undoubtedly 
tends  to  prevent  coagulation,  as  Peters  suggested.  When,  there- 
fore, the  syncytium  becomes  largely  altered  in  any  area  the  blood 
tends  to  coagulate  there,  and  in  this  way  the  contribution  of 
maternal  blood  to  the  infarct  is  brought  about. 

Finally,  when  several  villi  are  massed  together  by  a  fibrinous 
mass,  their  entire  stroma  gradually  undergoes  hyaline  degenera- 
tion, so  that  in  well-advanced  conditions  their  outlines  are  often 
scarcely  to  be  recognized. 

Occasionally  infarcts  are  found  in  which,  along  with  the  villi 
and  fibrin,  there  is  decidual  tissue.  No  doubt,  in  some  cases, 
large  cells  have  been  described  as  decidual  which  were  those  of 
the  Langhans  layer,  not  degenerated  ;  but  there  can  be  no  doubt 
that  decidual  tissue  may  sometimes  form  part  of  these  infarct 
masses.  The  appearance  is  produced  when  the  section  divides 
an  elevation  of  the  serotina  to  which  are  attached  villi  in  which 
the  fibrinous  changes  have  progressed.  Sometimes,  in  these, 
groups  of  the  Langhans  cells  may  also  be  seen,  for  I  have  already 
demonstrated  the  frequenc}'  \\'ith  which  these  cells  are  proliferated 
at  the  ends  of  the  attachment  of  villi  to  the  decidua,  and  the  varia- 
tions found  in  their  disappearance  as  pregnancy  advances. 

In  some  cases  the  infarct  masses  consist  only  of  degenerating 
villi  bound  together  without  any  blood-coagulation  around  themx. 
These  have  been  recently  termed  by  Eden  as  "  non-fibrinous  in- 
farcts." Kastschenko  was  the  first  to  describe  this  blending  of 
villi. 

The  red  infarct  consists  of  degenerating  villi  around  which  the 
blood  lias  coagulated  rapidh',  fibrin  formation  being,  therefore, 
little  developed. 

Infarct  formation  is  most  marked  in  women  with  albuminuria. 
It  is  found  in  connection  with  syphilis  and  other  diseased  condi- 
tions of  the  mother,  but  we  cannot  speak  with  any  accuracy  con- 
cerning the  relationship. 

Umbilical  Cord. — The  origin  of  the  umbilical  cord  has 
already  been  described.  (See  p.  28.)  Its  structure  varies  some- 
what at  different  stages  of  pregnancy.  In  the  early  weeks  it  is 
covered  with  a  single  layer  of  cubical  cells.  By  the  third  month 
there  are  two  la}'ers.  By  the  fifth  month  the  layers  are  more 
numerous  and  stratified,  the  superficial  cells  being  flattened  like 
those  of  the  skin.  In  its  development  the  cord  ectoderm  corre- 
sponds wdth  that  of  the  body,  though  it  is  more  slowly  altered. 
The  mesoderm,  in  the  early  weeks,  consists  of  a  network  of  nu- 
cleated protoplasm,  of  which  the  filaments  and  meshes  vary  in 


PLATE  5. 


A 


Portions  of  placentae  with  the  so-called  "white  infarcts."  A.  Uterine  surface 
of  part  of  placenta,  showing  pale  infarcted  areas  near  the  margin.  B,  Section 
through  part  of  placenta  near  margin,  showing  pale  area  extending  downward 
from  the  chorionic  layer  near  the  edge.  C,  Section  through  part  of  placenta,  show- 
ing pale  area  at  margin  continuous  with  the  chorionic  layer. 


rLA  CENTA  TION. 


69 


size ;  some  nuclei  have  no  protoplasm  around  them.  By  the 
fourth  month  the  network  is  simpler,  the  meshes  larger,  and  the 
filaments  fewer  and  coarser ;  connective-tissue  fibrils  have  begun 
to  develop.  Elastic  fibers  develop  chiefly  in  the  second  half  of 
pregnancy.  In  the  cord,  in  the  early  weeks,  the  following  struct- 
ures are  found  :  Two  umbilical  arteries  ;  two  umbilical  veins  ;  part 
of  the   allantois ;    duct    of  the  yolk-sac,  carrying  the  omphalo- 


Fig.  47. — Epithelial  covering  of  umbilical  cord  at  end  of  second  month.     X  nearly  550 
diameters,     a.  Epithelial  cells  in  two  layers;  b,  early  connective-tissue  core  of  cord. 

mesenteric  vessels ;  extension  of  the  celom  or  body-cavity  in 
which  the  omphalic  duct  lies.  In  the  celom  coils  of  intestines 
may  be  found  during  the  second  month  ;  sometimes  later. 

As  pregnancy  advances  the  celomic  tube,  omphalic  duct,  and 
allantoic  duct  gradually  become  less  m.arked,  in  the  order  named. 
Thus,  by  the  fourth  month  the  first  named  may  be  very  small, 
extending  only  a  short  distance  from  the  abdominal  wall  of  the 


f 

i--" 

\     ■ 

1  L^— ■ 

r^^v 

j),X^ 

'                    / 

V 

''' ) 

'-^y 

^ ,,' "    ! 

all. 

Fig.  48. — Diagrammatic  section  of  the  abdominal  stalk  {Bauchstiel)  of  human 
embryo.  Modified  from  W.  His  (after  Minot) :  am.  Amnion;  md,  medullary  groove; 
V,  V,  umbilical  veins  ;  a,  a,  umbilical  arteries  ;  all,  allantois  ;  coe,  celom. 

fetus.  The  omphalic  duct  becomes  shrivelled  and  usually  oblit- 
erated. The  allantoic  stalk  consists  of  a  tube  lined  by  two  or 
three  layers  of  endodermal  cells,  surrounded  by  somewhat  con- 
densed mesoderm  ;  usually  the  lumen  becomes  early  obliterated. 
This  structure  generally  persists  to  full  time  as  a  remnant,  which 
may  be  detected  in  the  fetal  end  of  the  cord.  One  of  the  umbil- 
ical veins,  usually  the  right,  becomes  obliterated  before  the  third 


70 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


month.     Many  variations  are  found  as  regards  the  changes  which 
take  place  in  these  various  structures. 

At  full  time  the  ectoderm  consists  of  several  layers  of  cells, 
stratified  and  resembling  early  skin.     The   connective  tissue   of 


CO 


Fig.  49. — Transverse  action  of  allantois  from  umbilical  cord  at  end  of  second 
month  of  pregnancy.  X  325  diameters,  a,  Epithelial  cells  of  hypoblastic  origin  ;  b, 
mesoblast  surrounding  epithelium. 

the  cord,  in  which  the  vessels  and  other  structures  lie,  is  termed 
Whartonian  jelly,  and  is  mainly  embryonic  mucoid  tissue ;  in  it 
w^ell-marked   connective-tissue  fibrils   run   in   different  directions. 


Fig.  50. — Two  sections  of  umbilical  cord  (alter  Minot).  X  20  diameters.  A,  At 
sixty  days  ;  B,  at  three  months,  v.  Umbilical  vein  ;  a,  a,  umbilical  arteries  ;  all,  allantois  ; 
coe,  celom  ;  y,  yolk-sac. 

Elastic  fibers  are  also  found.  So  far  as  is  known  no  nerves  or 
lymphatic  vessels  occur  in  the  cord.  The  spaces  of  the  connective 
tissue  have  by  some  been  described  as  communicating  with  the 
amniotic  cavity  by  stomata.     The  connective  tissue  varies  consid- 


ANATOMY  OF   THE   FETUS.  J I 

erably  in  density  in  different  parts.  In.  many  cases  it  is  condensed 
mainly  in  three  portions,  which  extend  from  the  allantoic  duct  as 
septa,  between  which  the  umbilical  vessels  run.  Wandering  white 
corpuscles  may  be  found  in  the  connective-tissue  spaces. 

There  are  two  umbilical  arteries  and  one  vein.  The  arteries 
have  no  elastic  layers,  and  a  very  thin  intima.  Their  walls  are 
mainly  muscular.  When  cut  across  they  contract  and  project, 
but  do  not  retract.  Their  caliber  increases  from  the  fetus  toward 
the  placenta.  The  vein  is  somewhat  like  the  artery,  its  intima 
being  more  distinct ;  in  it  are  found  ring-shaped  or  semilunar 
valves,  never,  however,  placed  opposite  one  another.  No  nerves 
or  vasa  vasorum  have  been  found  in  the  walls  of  the  vessels.  The 
latter  are  described  by  some  as  being  present  in  early  fetal  life. 
The  vessels  are  related  to  one  another  in  various  ways.  Usually 
the  arteries  are  coiled  around  the  vein,  running  from  right  to  left, 
causing  a  twisted  appearance  ;  sometimes  they  run  from  left  to 
right ;  sometimes  they  run  parallel  almost  the  whole  length  of 
the  cord ;  rarely  the  twist  is  from  left  to  right  and  from  right  to 
left  in  the  same  cord.  Occasionally  the  cord  is  split  into  two  por- 
tions, the  arteries  being  in  one  and  the  vein  in  the  other.  The 
explanation  of  the  twisted  arrangement  is  not  certain.  It  is 
undoubtedly  beneficial,  as  it  makes  the  cord  stronger  and  les- 
sens the  risk  of  compression,  at  the  same  time  steadying  and 
regulating  the  force  of  the  blood-stream  in  the  cord. 

Relation  to  the  Placenta. — The  placental  insertion  of  the 
cord  is  usually  eccentric,  rarely  central  or  marginal ;  sometimes  it 
is  attached  to  the  membranes,  "  velamentous  insertion."  The 
arteries  are  often  connected  by  a  transverse  branch  as  they  pass 
to  the  placenta,  about  half  an  inch  above  the  latter. 

Relation  to  thie  Fetus. — In  early  embiyonic  Hfe  the  cord  is 
attached  near  the  caudal  end.  By  the  time  the  limbs  are  formed 
it  is  connected  just  above  the  pubes.  The  insertion  gradually 
rises  during  pregnancy,  until  at  term  it  is  about  three-quarters  of 
an  inch  below  the  middle  of  the  fetus. 

ANATOMY  OF  THE  FETUS. 

The  earliest  outlining  of  the  external  form  of  the  human 
embryo  takes  place  about  the  end  of  the  second  week.  His  has 
described  specimens  which  he  believed  to  be  respectively  thirteen 
and  fifteen  days  old.  In  these  the  characteristic  feature  is  the 
dorsal  concavity.  The  embryo  is  enclosed  in  the  amnion.  The 
caudal  end  is  connected  with  the  primitive  chorion  by  the  ventral 
.stalk,  which  is  almost  in  line  with  the  long  axis  of  the  embryo. 
The  umbilical  vesicle  communicates  freely  with  the  wide-open 
intestinal  canal. 

Twciity-Jirst  Day. — The  first  rudiments  of  the  limbs  appear  as 
little  buds. 


72 


AA'ATOA/V  AND   PHYSIOLOGY  OF  PREGNANCY. 


Twenty-third  Day. — Between  the  twenty-first  and  twenty- 
third  days  the  dorsal  concavity  changes  to  a  marked  convexity, 
the  caudal  and  cephalic  ends  overlapping.  After  this  day  the 
convexity  is  less  marked. 

Fourth  Week. — The  visceral  arches  and  clefts  develop.  Com- 
munication between  the  umbilical  vesicle  and  the  intestinal  tract 
is  reduced  to  a  narrow  vitelline  duct.  A  well-marked  tail  is 
present  by  the  twenty-fifth  day.  (His  has  termed  the  period  of 
the  third  and  fourth  weeks  the  embiyonic  stage,  and  the  re- 
mainder of  pregnancy  the  fetal  stage.) 

Second  Month. — During  this  month  the  rate  of  growth  is  less 


Fig.  51. — Human  embryo  of  about  the  thirteenth  day  (His).  The  caudal  pole  of 
the  embryo  is  connected  with  the  blastodermic  vesicle  by  means  of  the  abdominal 
stalk;  the  amnion  completely  encloses  the  embryo,  and  the  large  vitelline  sac  com- 
municates throughout  the  greater  part  of  the  ventral  surface  by  means  of  the  unclosed 
sut-tract. 


rapid.  The  convexity  of  the  body  diminishes  somewhat,  the 
head  being  gradually  raised.  The  vitelline  duct  is  elongated. 
Intestines  bulge  into  the  umbilical  cord.  The  abdomen  is  very 
prominent.  The  limbs  become  differentiated  into  their  component 
parts,  the  upper  being  first  developed.  The  external  parts  of  the 
eye,  ear,  nose,  and  mouth  become  marked.  Ossification  begins  in 
the  lower  jaw.  In  the  eighth  week  the  tail  disappears  and  the 
external  genitals  develop,  without,  however,  any  distinction  of 
sex. 

Third  Hlonth. — Nails  appear  on  fingers  and  toes.  The  external 
genitals  begin  to  show  sex  character. 

FourtJi  Month. — Lanugo,  a  growth  of  fine  hair,  appears  on  the 


ANATOMY  OF   THE   FETUS. 


73 


head  and  other  parts.  The  anus  opens.  The  intestines  are  con- 
tained entirely  within  the  body-cavity.  The  umbihcus  is  close  to 
the  pubes.  The  spinal  cord  extends  the  whole  length  of  the 
spinal  canal. 

Fifth  Month. — Fetal  movements  are  usually  felt  by  the 
mother.  Heart  sounds  are  perceptible.  Eyelids  begin  to  sepa- 
rate.    Trace  of  bile  in  the  intestines. 

Sixth  Month. — Skin  wrinkled,  dirty  red  in  color,  and  coated 
with  vernix  caseosa.      Eyebrows  and  eyelashes  appear. 

Seventh  MontJi. — Skin  is  less  wrinkled,  owing  to  development 
of  subcutaneous  fat.     Meconium  is  found  throughout  the  large 


Fig.  52. — Human  embryo  of  about  the  fifteenth  day  (His).  The  embryo  is  attached 
to  the  wall  of  the  blastodermic  vesicle  by  means  of  the  abdominal  stalk,  and  is  enclosed 
within  the  amnion;  the  large  vitelline  sac  freely  communicates  with  the  still  wide-open 
gut. 


intestine.  Testes  are  at  internal  abdominal  rings  or  in  inguinal 
canals.     Nails  break  through  epidermal  coverings. 

Eighth  Month. — Bulk  of  fetus  increases  proportionately  more 
than  length.  Skin  has  brighter  flesh  color  and  is  less  wrinkled. 
Lanugo  begins  to  disappear. 

Ninth  Month. — Body  of  fetus  well  rounded.  Lanugo  mostly 
gone.  Umbilicus  almost  in  middle  of  body.  End  of  spinal  cord 
is  at  level  of  first  lumbar  vertebra.  The  first  epiphyseal  ossifica- 
tion appears  in  lower  end  of  femur.  Sometimes  it  develops  also 
in  upper  epiphyses  of  humerus  and  tibia. 

Si^e  of  the  Fetus. — The  fetus  varies  in  size  at  corresponding 
periods  of  development  in  different  cases.     Various  tables  have 


74  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


Fig.  53. — Early  human  embryos,  all  enlarged  about  two  and  a  half  times  (His): 
1-4,  From  twelfth  to  fifteenth  day;  5,  6,  from  eighteenth  to  twenty-first  day;  7,  8,  from 
twenty-third  to  twentv-fifth  day;  9-12,  from  twenty-seventh  to  thirtieth  day;  13-17, 
from  thirty-first  to  thirty-fourth  day.  rt'/w,  Amnion  ;  ?/t',  umbilical  or  vitelline  vesicle; 
als,  allantoic  or  abdominal  stalk;  c,  r',  brain  vesicles  ;  h,  heart;  va,  visceral  arches; 
<7,  optic  vesicle;  ot,  otic  vesicle;  ol,  olfactory  pit ;  /, /',  upper  and  lower  extremities; 
J,  somites ;  cd,  caudal  process  ;  u,  primitive  umbilical  cord. 


been  drawn  up,  givang  the  length  and  weight  at  different  months. 
Hasse  calculates  the  length  in  centimeters  as  follows : 


ANATOMY  OF   THE   FETUS. 


At  the  end  of  i  lu 

"  3 

"  4 

"  5 

"  6 

"  7 

"  8 

"  9 

"              "  lO 


ar  month    length  of  fetus  is I  cm. 

months             "               "       4   " 

"       9   " 

"       16  " 

"       25   " 

"       30  " 

"      35  " 

"      40  " 

"      45  " 

50  " 


The  length  equals  the  number  of  months  up  to  the  fifth  multi- 
plied by  the  same  figure  ;  after  the  fifth  the  number  of  months 
multiplied  by  five.  The  lengths  are  a  little  too  large  for  the  early 
months,  though  satisfactory  for  the  later  ones. 

Expressed  in  inches,  the  length  may  be  stated  as  follows : 


At  the  end  of 


I  lu 

2 

3 

4 

5 

6 

7 


nar  month  O.^ 
months     ] 


in.  (about),  straight  line  from  head  to  tail, 
to     \\ 


3  to    3j 

4  to    6i 
7  to  \o\ 

II  to  13,^ 

n\  to  15I 

15^-  to  1^\ 
16J-  to  17J 
17I-  to  i8i 


Weight  of  the  Fetus. — Many  variations  are  found  in  the 
weight  of  the  fetus  at  different  periods  in  various  specimens. 

At  the  end  of  2  months  average  weight  is  4-5  gm. 


3 

'        wei 

ght  is 

5-     20 

'  — average, 

II  gm 

4 

' 

10-   120 

'  —       " 

57    " 

5 

75-  500    ' 

'  —       " 

285    " 

6 

' 

375-1280 

'  —  -     " 

635    " 

7 

' 

785-2250 

'  —       " 

1218    " 

8 

' 

1095-2440 

•  —       " 

1569    " 

9 

' 

1500-2905    ' 

'  —       " 

1971    " 

0 

i 

30C0-3600 

'  —       " 

3200    <' 

The  average  full-time  weight  of  the  single  fetus  is  a  little  over 
7  pounds ;  the  average  in  the  case  of  males  being  about  7^,  and 
in  the  case  of  females  7  pounds.  Full-time  infants  weighing  more 
than  10  pounds  are  very  rare.  Mrs.  Bates,  the  Nova  Scotia  giant- 
ess, bore  two  children,  the  first  weighing  at  birth  19  pounds,  and 
the  second  2^\  pounds.  In  the  case  of  multiple  pregnancies  a 
fetus  may  be  extremely  small,  though  well  developed.  Harris 
has  reported  one  weighing  i  pound.  Frequently  they  may  weigh 
between  2\  and  4  pounds. 

The  explanation  of  variations  in  the  size  of  the  full-time  fetus 
cannot  be  fully  given.  There  are  differences  according  to  se.x,  males 
being  larger  than  females.  Young  mothers  have,  on  the  average, 
.smaller  infants  than   those  who  are  more  mature.     Those  born 


76 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


of  mothers  between  thirty  and  thirty-five  are  said  to  be  the  heav- 
iest. Infants  of  the  same  sex  weigh  more  in  successive  preg- 
nancies, if  they  are  not  born  too  close  together.  In  the  case  of 
primiparae,  therefore,  the  average  weight  of  infants  is  less  than 
in  multiparse.  The  weight  varies  directly  with  that  of  the  mother. 
Conditions  seriously  affecting  the  health  tend  to  interfere  with  the 


Fig.  54. — Diagram  illustrating  the  outlines  of  the  human  fetus  at  various  stages 
from  the  end  of  the  second  to  the  end  of  the  eighth  week,  magnified  four  times  (modi- 
fied after  Mali). 


development  of  the  fetus.     Some  women  and  families  tend  to  give 
birth  to  small  children  ;  others  have  the  opposite  tendency. 

Some  Anatomic  Peculiarities  of  the  Fetus  at  Full 
Time. — Head. — The  cranium  is  relatively  much  larger  than  the 
face,  the  disproportion  being  more  marked  than  in  the  adult,  and 
being  due  to  the  small  development  of  the  face  region.    The  vault 


ANATOMY  OF   THE   FETUS. 


77 


Fig.  55. — Human  embryo  of  about  three  weeks,  showing  visceral  arches  and  furrows 
and  their  relations  to  aortic  arches  (His) :  mx,  mn,  Maxillary  and  mandibular  processes 
of  first  visceral  arch;  a  I-a  IV,  first  to  fourth  aortic  arches;  Jv,  cv,  primitive  jugular 
and  cardinal  veins;  dC,  duct  of  Cuvier;  at,  v,  atrium  and  ventricle  of  primitive  heart; 
vs,  vitelline  sac ;  va,  da,  ventral  and  dorsal  aortae ;  ov,  ot,  optic  and  otic  vesicles;  uv,  ua, 
umbilical  veins  and  arteries;  vv,  vitelline  vein  ;  al,  allantois. 


and  base  of  the  cranium  differ  considerably  in  respect  to  the  rela- 
tionship of  their  constituent  parts,  the  bones  composing  the  former 
being  thinner  and  more  loosely  joined  together.     The  importance 


yS  AiVATOMV  AXD   PHYSIOLOGY  OF  PREGNANCY. 

of  this  difference  is  seen  in  labor.  When  the  head  is  subjected  to 
pressure  the  vault  can  be  considerably  altered  in  shape,  whereas 
the  base  remains  firm,  thus  affording  protection  to  the  important 
nerve  structures  lying  upon  it.  The  heads  of  males  are,  on  the 
average,  larger  and  more  ossified  than  those  of  females.  (A 
detailed  description  of  the  head  is  given  in  connection  \\ith  the 
Mechanism  of  Labor.j     (See  p.  199.) 

Heart  and  Blood=vessels. — The  size  of  the  heart  is  approxi- 
matel}-  that  of  the  closed  fist  of  the  fetus  to  which  it  belongs.  Its 
weight  is  relatively  greater  than  in  the  adult,  but  there  is  practi- 
cally no  difference,  relatively,  as  regards  size.  The  heart  is  placed 
more  transversely  and  a  little  higher  than  in  the  adult.  In  the 
septum  between  the  right  and  left  auricles  is  an  opening,  the 
foramen  ovale.  In  connection  with  this,  in  the  right  auricle,  is 
a  fold  of  the  lining,  known  as  the  Eustachian  \alve.  A  canal, 
termed  the  ductus  arteriosus,  joins  the  pulmonary  arteiy  to  the 
aorta.  From  each  hypogastric  branch  of  the  internal  iliac  arteries 
a  vessel  known  as  the  umbilical  arter}'  extends  to  the  cord  through 
the  navel ;  they  are  distributed  to  the  \  illi  of  the  placenta.  The 
umbilical  vein,  on  entering  the  fetus,  is  continuous  with  the  ductus 
veiiosus,  which,  runs  on  the  under  surface  of  the  liver  to  the  inferior 
veil  a  cava. 

Thymus. — The  large  size  of  the  gland  is  a  striking  feature. 
It  lies  in  the  anterior  mediastinum,  consisting  of  a  right  and  a  left 
lobe,  and  sometimes  of  an  intermediate  one,  as  well.  Its  upper 
limit  is  above  the  suprasternal  notch,  where  it  almost  reaches  the 
isthmus  of  the  thyroid,  its  lower  level  being  near  the  diaphragm. 
Posteriorly  it  is  in  relation  to  the  large  vessels  connected  with  the 
base  of  the  heart,  to  a  considerable  part  of  the  pericardium,  and 
to  the  pleura  covering  the  lungs.  By  some  this  gland  is  regarded 
as  the  parent  source  of  the  white  blood-corpuscles. 

Lungs. — The  lungs  are  placed  at  the  back  of  the  thorax. 
They  are  uniform  in  color ;  in  texture  and  consistence  somewhat 
resembling  the  liver.  The  surface  is  marked  by  slight  furrows, 
faintly  indicating  lobular  division.  The  anterior  and  lower  borders 
are  thin  and  sharp.  The  area  of  chest-wall  in  contact  with  the 
lungs  is  relatively  ver\'  much  smaller  than  in  the  adult. 

Diaphragm. — This  is  relatively  higher  in  its  central  portion 
than  in  adult  life. 

Liver. — This  structure  is  very  large,  occupying  nearly  one- 
half  of  the  abdominal  cavity.  The  left  lobe  is  relatively  much 
larger  than  in  the  adult.  The  longitudinal  fissure  is  very  deep, 
containing  the  ductus  venosus  and  umbilical  vein. 

Stomach. — The  stomach  is  of  small  size,  and  at  birth  can 
hold  only  i  to  \\  ounces  of  fluid  without  being  overdistended. 
At  that  period  it  is  either  empty  or  contains  mucus  or  liquor 
amnii.     Vernix  caseosa  and  meconium  are  sometimes  found  in  it. 


ANATOMY  OF   THE   FETUS.  79 

The  viscus  lies  largely  under  cover  of  the  left  lobe  of  the  liver, 
the  fundus  being  poorly  developed. 

Suprarenal  Bodies. — These  structures  are  about  one-third  of 
the  size  of  the  kidney,  being,  therefore,  relatively  larger  than  in 
the  adult.  Each  has  the  shape  of  a  three-sided  pyramid,  resting 
upon  the  upper  end  and  anterior  surface  of  the  kidney. 

Kidneys. — The  relations  of  the  kidneys  are  not  very  different 
from  those  found  in  the  adult,  except  that  the  suprarenal  body 
covers  more  of  its  anterior  surface.  The  surface  is  somewhat 
lobulated. 

Umbilicus. — The  attachment  of  the  cord  to  the  abdomen  is 
relatively  lower  than  in  the  adult.  It  is  opposite  the  junction  of 
the  fourth  and  fifth  lumbar  vertebras  ;  whereas  in  the  adult  it  is 
opposite  the  junction  of  the  third  and  fourth. 

Bladder. — This  viscus  is  almost  entirely  an  abdominal  organ, 
its  position  and  shape  varying  according  to  the  amount  of  urine 
in  it  and  according  to  the  pressure  exerted  upon  it  by  other 
pelvic  and  abdominal  contents.  When  empty  the  upper  end 
reaches  almost  halfway  to  the  umbilicus  ;  when  distended  it  may 
reach  the  umbilicus,  or  even  higher.  The  vesical  end  of  the 
urethra  is  situated  about  opposite  the  top  of  the  symphysis.  In 
the  empty  condition  the  anterior  and  posterior  walls  lie  in  apposi- 
tion, the  cavity  being  then  in  a  direct  line  with  the  urethra  in  the 
female.  The  upper  portion  is  smaller  than  the  lower,  the  viscus, 
when  moderately  distended,  having  an  ovoid  shape,  the  broad  end 
being  lowermost.  It  is  only  in  an  overdistended  condition  that 
the  upper  part  of  the  bladder  becomes  larger  than  the  lower. 
The  anterior  wall  is  attached  to  the  anterior  abdominal  wall,  there 
being  no  intervening  pouch  of  peritoneum.  The  peritoneal  re- 
flection takes  place  2  to  3  cm.  above  the  symphysis,  a  short  distance 
below  the  umbiHcus.  The  vertical  length  of  the  cavity,  when 
empty,  measures  from  2  to  2.5  cm.  It  rarely  contains  more  than 
I  to  i|-  drams  at  the  time  of  birth. 

Urethra. — In  the  female  it  is  parallel  to  the  axis  of  the  pelvis, 
turning  slightly  forward  at  the  lower  end,  the  external  orifice 
being  slightly  in  front  of  a  line  drawn  vertically  from  the  sym- 
physis. A  No.  10  catheter  may  usually  be  passed  into  the 
bladder,  though  it  is  not  necessary  to  use  one  as  large  as  this  in 
the  newborn  child. 

Rectum. — The  rectum  is  relatively  larger  and  less  curved  than 
in  the  adult.  It  is  almost  a  straight  vertical  tube  in  the  erect 
position  of  the  body.  The  anus  is  directed  downward  and  slightly 
backward,  being  situated  relatively  further  back  than  in  the  adult. 
It  does  not  lie  in  a  depression  between  the  buttocks,  as  in  the 
adult,  owing  to  the  small  development  of  the  gluteal  regions. 

Uterus. — The  uterus  at  full  time  is  partly  a  pelvic,  partly  an 
abdominal,  organ.     Its  position  varies  according  to  the  pressure 


8o  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 

exerted  upon  it  by  the  bladder  and  intestines.  When  these 
structures  are  empty  probably  the  larger  part  of  the  uterus  lies 
below  the  level  of  the  brim.  The  long  axis  is  mainly  vertical,  a 
slight  degree  of  anteversion  being  common.  Frequently  the 
fundus  may  be  directed  somewhat  to  the  right  or  left.  Some- 
times rotation  on  the  long  axis  is  present.  Occasionally  there  is 
a  slight  degree  of  anteflexion  at  the  junction  of  the  body  and 
cervix.  Rarely  retroversion  is  met.  In  one  instance  I  found 
retroflexion  present,  though  the  organ  was  anteverted.  The 
average  length  measures  about  3  cm.  The  cervix  is  much  larger 
than  the  body,  its  length  being  two  or  three  times  as  great.  The 
folds  of  the  arbor  vitae  extend  to  the  fundus.  On  the  vaginal 
surface  of  the  cervix  rugae  are  sometimes  seen. 

Vagina. — The  \agina  runs  almost  vertically,  being  nearly 
parallel  with  the  rectum  and  urethra.  It  forms  a  very  obtuse 
angle  with  the  uterus.  In  transverse  section  it  is  H-shaped,  the 
anterior  and  posterior  walls  being  in  contact  in  the  middle  line. 

Fallopian  Tubes. — The  Fallopian  tubes  average  2  to  3  cm.  in 
length,  the  right  beingr  usuallv  a  little  longer  than  the  left.  Each 
has  three  to  fi\e  sinuosities.  The}'  extend  from  the  uterus  out- 
ward and  slightly  backward,  man}-  \ariations  being  found  in  their 
shape  and  direction. 

Ovaries. — The  ovaries  lie  somewhat  verticall}^  near  the  uterus, 
above  the  plane  of  the  brim,  many  variations  in  their  position 
being  found. 

External  Genitals. — In  the  female  the  labia  majora  are  rela- 
tivel}'  smaller  than  in  the  adult,  the  labia  minora  being  not  so 
hidden  from  view  as  in  later  life.  The  labia  minora  do  not  blend 
posteriorly  with  the  labia  majora,  but  are  united  behind  the 
introitus  vagina;  b}*  the  ridge  known  as  the  fourchette. 

FETAL  PHYSIOLOGY. 

Nutrition. — In  the  earliest  stage  after  fertilization  of  the 
ovum  its  nutriment  is  probabh^  derived  from  the  }-olk-particles 
belonging  to  the  original  ovum.  As  it  passes  downward  to  the 
uterus  it  probably  absorbs  fluids  from  the  tube-lumen  by  endos- 
mosis.  When  trophoblast  proliferation  occurs  in  connection  with 
embedding  of  the  ovum  in  the  uterine  mucosa,  direct  absorption 
from  maternal  tissues  probably  takes  place.  When  the  omphalo- 
mesenteric circulation  is  established  in  the  wall  of  the  umbilical 
vesicle  ^    a    small    amount  of  nourishment  ma}',  through    them, 

'  The  yolk-sac  does  not  serve  such  an  important  function  in  affording  a  direct 
food  supply  among  mammalians  as  in  the  other  vertebrata.  Yet  in  several  of  the 
former — /.  e.,  insectivora,  cheiroptera,  rodentia,  it  is  specialized  to  play  an  impor- 
tant part.  It  enlarges  and  enters  into  relationship  with  the  diplotrophoblast,  forming 
a  temporary  connection  between  the  mother  and  fetus,  the  vitelline  or  omphaloidean 
placenta,   the  fetus  being  nourished  by  the  vitelline  or  omphalomesenteric  vessels. 


FETAL    PHYSIOLOGY.  81 

reach  the  fetus,  but  this  is  a  very  insignificant  supply.  The  chief 
source  of  nourishment  during  pregnancy  is  the  maternal  blood 
circulating  in  the  intervillous  spaces,  all  the  materials  necessary 
to  the  fetus  passing  through  the  walls  of  the  villi  and  entering 
the  fetal  vessels  within  the  latter.  The  nature  of  this  transmission 
is,  as  yet,  unknown.  The  liquor  amnii  may  furnish  an  infinites- 
imal quantity  of  nourishment,  absorbed  after  being  swallowed. 
That  it  is  not  important  is  evident  from  cases  in  which  the  fetus  is 
well-nourished,  though  the  liquor  amnii  be  very  scanty  or  the 
esophagus  be  imperforate. 

Respiration. — In  the  villi  the  impure  fetal  blood  brought  to 
them  by  branches  of  the  umbilical  arteries  is  oxygenated  and 
purified,  the  carbonic  acid  and  other  products  of  tissue  waste 
escaping  through  the  villi  into  the  maternal  blood,  and  by  it 
carried  away  to  the  various  excretory  organs  of  the  mother.  The 
process  is,  therefore,  somewhat  similar  to  that  which  occurs  in 
the  pulmonary  circulation  of  the  adult,  only  in  the  latter  the  air 
in  the  lung  vesicles  corresponds  to  the  maternal  blood  in  the 
intervillous  spaces.  The  fetal  blood  is  rich  in  oxygen  derived 
from  the  red  blood-corpuscles  of  the  maternal  blood ;  indeed,  it 
seems  as  if  it  held  a  greater  quantity  than  is  essential.  The  differ- 
ence between  the  quantities  of  oxygen  in  the  umbilical  vein  and 
arteries  is  much  less  than  that  existing  between  arterial  and 
venous  blood  in  the  child  after  birth.  The  spectroscope  shows 
oxyhemoglobin  bands. 

Fetal  Circulation. — After  the  placenta  has  been  well  formed 
and  the  villi  vascularized  the  circulation  in  the  vessels  of  the  fetus 
has  the  following  arrangement :  The  blood  in  the  umbiHcal  vein 
(in  the  early  stages  there  are  two  veins)  is  that  which  has  been 
purified  in  the  capillaries  of  the  villi.  This  vessel,  on  enter- 
ing the  fetus  at  the  navel,  passes  along  the  abdominal  wall  to 
the  under  surface  of  the  liver,  giving  some  small  branches  to 
the  latter.  On  reaching  the  transverse  fissure  it  divides  into  two 
parts,  the  larger  of  which  enters  the  portal  vein.  The  smaller, 
known  as  the  ductus  venosus,  opens  into  the  inferior  vena  cava. 
The  great  mass  of  the  pure  blood  thus  brought  from  the  villi 
passes  through  the  liver  before  reaching  the  auricle  of  the  heart ; 

Later  this  placenta  is  replaced  by  the  allantoic  placenta.  In  the  human  female  it 
is  probable  that  occasionally,  in  the  case  of  the  sympodial  monstrosity,  the  perma- 
nent placenta  is  supplied  by  the  vessels  of  the  umbilical  vesicle.  In  the  marsupials 
there  is  no  true  placenta,  the  umbilical  vesicle  serving  to  absorb  nourishment  from 
the  mother  before  the  fetus  is  transferred  to  the  marsupium.  In  the  human  cord, 
occasionally,  pervious  vitelline  vessels  may  be  discovered  at  full  time.  Ordinarily, 
however,  these  vessels  and  the  duct  of  the  umbilical  vesicle  are  early  obliterated. 
Rarely  that  part  of  the  latter  within  the  fetus  remains  and  is  known  as  Meckel's 
diverticulum,  which  may  be  free,  attached  to  the  umbilicus  or  abdominal  wall,  or 
may  open  on  the  surface,  forming  a  fistula.  The  umbilical  vesicle  may  frequently 
be  found  as  a  very  small  cyst  under  the  amnion,  near  the  insertion  of  the  cord  into 
the  placenta. 


82  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 

the  rest  of  the  blood  passing  through  the  ductus  venosus  mixes 
with  impure  blood  in  the  inferior  vena  cava  returning  from  the 
lower  portion  of  the  fetus.  The  stream,  therefore,  which  enters 
the  right  auricle  consists  mainly  of  purified  blood.  It  passes  into 
the  left  auricle  by  way  of  the  foramen  ovale,  being  guided  by  the 
Eustachian  valve.  From  the  left  auricle  the  blood  enters  the  left 
ventricle,  thence  into  the  aorta,  from  which  it  largely  passes  into 
the  branches  supplying  the  head  and  upper  extremities.  It  con- 
tinues down  the  descending  arch  of  the  aorta,  where  it  is  joined 
by  impure  blood  which  has  passed  through  the  ductus  arteriosus 
from  the  pulmonary  artery.  This  impure  blood  is  derived  from 
the  veins  of  the  head  and  upper  extremities,  and  enters  the  right 
auricle  through  the  superior  vena  cava ;  it  crosses  the  stream  of 
pure  blood  without  mixing  with  it  to  any  extent,  and  passes 
through  the  tricuspid  valve  into  the  right  ventricle,  whence  it 
escapes  by  the  pulmonary  artery.  As  the  lungs  are  functionless 
there  is  no  need  for  a  pulmonary  circulation  similar  to  that  wdiich 
exists  in  the  adult.  Only  a  small  quantity  goes  to  these  structures 
to  keep  up  their  nutrition.  The  main  current  of  the  blood  passes 
through  the  ductus  arteriosus  to  join  the  more  purified  blood 
descending  through  the  aorta.  It  is  thus  evident  that  the  head 
and  upper  extremities  are  supplied  by  a  much  purer  blood  than 
the  lower  part  of  the  body ;  this  arrangement  is  undoubtedly  re- 
lated to  the  necessity  of  supplying  the  best  nourishment  for  the 
rapidly  developing  brain  centers.  In  the  last  weeks  of  pregnancy 
the  Eustachian  valve  often  shrinks  somewhat,  so  that  more  blend- 
ing of  the  two  blood-currents  occurs  in  the  right  auricle.  In  con- 
sequence of  this  mixing  the  head  supply  is  less  pure,  while  that 
going  to  the  lower  part  of  the  body  is  less  impure  as  the  end  of 
pregnancy  approaches.  The  lower  part  of  the  body,  as  might  be 
expected,  grows  more  rapidly  during  the  last  weeks,  while  the 
increase  in  the  head  and  upper  extremities  shows,  relatively,  a 
smaller  increase.  From  the  internal  iliac  division  of  each  iliac 
branch  of  the  aorta  the  hypogastric  arteries  cany  blood,  largely 
impure,  to  the  umbilical  cord,  in  w^hich  they  run  as  the  umbilical 
arteries,  giving  rise  to  the  capillary  loops  in  the  villi,  which  carry 
the  blood-stream  into  branches  of  the  umbiHcal  vein.  The  nature 
of  the  interchange  of  materials  between  the  circulation  of  the  fetal 
blood  in  the  villi  and  that  of  the  maternal  blood  in  the  intervillous 
spaces  is  not  at  all  well  understood. 

Changes  after  Birth. — When  the  cord  is  divided  and  res- 
piration has  begun,  more  blood  passes  through  the  pulmonaiy 
arteries  from  the  right  ventricle  and  less  through  the  ductus 
arteriosus  into  the  aorta.  With  the  entrance  into  the  left  auricle 
of  blood  from  the  pulmonary  veins,  less  enters  it  from  the  right 
auricle  through  the  foramen  ovale ;  and,  at  the  same  time,  the 
stream  passing  from  the  right  auricle  into  the  right  ventricle  is 


r>      P      - 


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FETAL    PHYSIOLOGY.  83 

larger.  By  the  eighth  or  tenth  day  the  ductus  arteriosus  is  closed  in 
the  great  majority  of  cases ;  a  few  weeks  after  birth  it  is  a  fibrous 
eord,  the  ligamentum  arteriosum.  The  foramen  ovale  closes  about 
the  end  of  the  first  week  in  most  cases,  but  this  may  take  place 
earlier  or  as  late  as  the  third  week.  Rarely  it  may  remain  as  a 
small  opening  for  a  year  or  more.  Occasionally  it  is  permanently 
patent,  leading  to  a  mixture  of  arterial  and  venous  blood,  which 
causes  blueness  of  the  body,  the  condition  known  in  infancy  as 
cyanosis  neonatorum,  and  in  the  adult  morbus  coeruleiis.  By  the 
fourth  day  after  birth  those  portions  of  the  hypogastric  arteries 
which  passed  from  the  sides  of  the  bladder  to  the  umbilical  cord 
have  shrunk  and  closed.  The  umbilical  vein  and  ductus  venosus 
are  obliterated  by  the  end  of  the  first  week. 

During  the  first  year  the  left  ventricle  hypertrophies,  so  that 
its  wall  becomes  double  that  of  the  right  in  thickness.  The  wall 
of  the  right  auricle  at  birth  is  thicker  than  the  left,  but  from  the 
second  month  to  the  end  of  the  first  year  they  are  equal  in  thick- 
ness ;  afterward  the  right  increases  a  little  over  the  left. 

Blood  in  the  Newborn  Child. — The  red  blood-corpuscles  are 
relatively  more  numerous  than  in  the  adult.  Aitken  states  that 
the  count  is  greater  during  the  first  forty-eight  hours,  owing  to 
concentration  of  blood  (due  to  loss  of  urine,  perspiration,  fasting, 
etc.).  After  the  second  day  there  is  a  fall  in  the  number,  until  by 
the  tenth  day  there  are  less  than  at  birth.  Nucleated  red  cells — 
normoblasts  and  megaloblasts — are  found  at  birth  and  during  the 
first  week.  Variations  in  the  size  and  shape  of  the  red  cells  and 
deficiency  in  rouleaux  formation  are  noted.  The  percentage  of 
hemoglobin  is  higher  at  birth  than  in  the  adult,  but  not  as  high 
as  it  is  a  few  days  later.  The  white  corpuscles  are  two  or  three 
times  as  numerous  as  in  the  adult.  Aitken  states  that  they  increase 
during  the  first  two  days,  thereafter  decreasing,  being  less  numer- 
ous than  at  birth  by  the  tenth  day.  The  lymphocytes  are  more 
abundant  than  the  neutrophiles  at  birth.  The  latter  increase  enor- 
mously after  the  first  feeding,  and  gradually  decrease  afterward. 
The  eosinophiles  are  usually  more  numerous  than  in  the  adult. 
The  amount  of  fibrin  is  small.  Nucleon,  or  phosphocarnic  acid,  has 
been  found  in  the  fetal  blood  by  Sfameni.  The  freezing-point  of 
the  fetal  blood  at  birth  is  lower  than  that  of  the  maternal  blood,  and 
its  density  (1060)  is  greater,  though  the  former  contains  slightly 
more  water  than  the  latter,  Runge  states  that  fetal  blood  is 
richer  in  salts  at  the  time  of  birth,  especially  in  undissolved  salts. 
Sfameni  gives  the  average  composition  of  fetal  blood  as  follows  : 

Per  cent. 

Water 78.52 


Solids 


21.47 


Organic 20.72 

Inorganic 0-74 

SoluVjle  salts 0.62 

Insoluble 0.12 


84  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 

Hugounenq  states  that  50  to  60  per  cent,  of  the  total  quantity 
of  iron  in  the  fetus  is  in  the  blood. 

Heat  Production. — The  fetus  does  not  waste  much  energy 
in  heat  production  because  of  the  temperature  of  the  surrounding 
liquor  amnii,  which  is  nearly  as  warm  as  the  fetal  blood.  There 
is  no  loss  of  heat  by  radiation  or  evaporation  which  requires  to 
be  made  up.  Neither  is  anything  taken  into  the  lungs  or  stomach 
which  must  be  warmed. 

The  temperature  of  the  mouth  or  rectum  of  the  fetus  during 
labor  is  very  slightly  {^  to  -^-^  C.)  higher  than  that  of  the  neigh- 
boring maternal  tissues.  It  is  higher  in  well-de\'eloped  infants 
than  in  weakly  ones.  The  temperature  of  the  liquor  amnii  is 
intermediate  between  the  maternal  and  fetal.  It  is,  therefore, 
evident  that  the  fetus  produces  heat  to  a  certain  extent,  though 
fetal  oxidation  is  feeble.  In  experiments  on  animals  it  has  been 
shown  that  the  fetal  temperature  rises  or  falls  according  as  the 
mother  gains  or  loses  heat.  Preyer  thinks  that  the  fetus  does  not 
possess  a  heat-regulating  mechanism. 

Alimentary  Functions. — The  fetus  in  ntcro  has  the  power 
of  swallowing.  As  regards  the  activity  of  the  glands  in  the 
alimentary  tract,  information  is  imperfect.  There  is  very  scanty 
elaboration  in  all  the  glands  connected  with  the  mouth.  A  slight 
trace  of  ptyalin  is  found  in  the  parotid  secretion.  In  the  gastric 
juice  pepsin  and  rennin  are  present  at  the  time  of  birth,  many 
variations  in  the  quantity  being  found.  Ballantyne  states  that 
there  is  enough  digestive  ferment  in  the  stomach  to  digest  all  the 
albuminous  material  swallowed  in  the  liquor  amnii.  Of  the  pan- 
creatic ferments,  tr}'psin  and  steapsin  or  pancreatin  are  found. 
The  former  has  been  found  as  early  as  the  fifth  month ;  some 
have  been  unable  to  detect  it.  The}-  undoubtedly  serve  an  im- 
portant function  in  digesting  the  proteids  and  fats  of  milk  after 
birth.  Amylopsin,  the  starch-digesting  ferment,  is  absent.  As 
regards  the  intestines,  Werker  has  shown  that  Brunner's  glands 
are  relatively  more  numerous  than  in  the  adult  state  ;  the  sig- 
nificance of  this  is  not  known.  The  large  size  of  the  liver  is 
related  to  an  influence  in  fetal  life  not  well  understood.  The 
glycogenic  function  is  probably  ver}'  important.  Bile  is  found 
in  the  intestines  as  early  as  the  third  or  fourth  month ;  bile  acids 
and  pigments  may  be  demonstrated  in  it. 

Meconium  is  always  found  after  the  fifth  month,  though  it  may 
be  present  before  that  time.  It  is  undoubtedly  largely  made  up 
of  bile,  for  it  is  never  found  where  bile  cannot  enter  the  intestine. 
It  is  formed  independently  of  the  liquor  amnii,  for  it  occurs  in 
conditions  which  prevent  this  fluid  from  entering  the  bowel.  But 
while  bile  is  the  most  important  constituent,  liquor  amnii  may 
often  be  mixed  with  it ;  also  vernix  caseosa,  lanugo,  and  skin  epi- 
thelium which  have  been  swallowed,  intestinal  epithelium,  leuko- 


FETAL    PHYSIOLOGY.  85 

cytes,  and  the  constituents  of  mucus.  Zweifel's  analysis  of  meco- 
nium shows  that  soHds  vary  from  20  to  27  per  cent,  of  the  whole, 
I  per  cent,  consisting  of  inorganic  salts — viz.,  sodium  chlorid,  iron 
oxid,  sulphates  and  phosphates  of  magnesia  and  calcium.  Altered 
bile  salts,  mucin,  and  bile  pigments  make  up  the  main  part  of  the 
organic  solid. 

Intestinal  peristalsis  is  not  active  in  antenatal  life.  It  is  rare  to 
find  meconium  in  the  liquor  amnii  save  in  cases  of  asphyxia. 

Renal  Function. — In  early  fetal  life  the  Wolffian  bodies  and 
ducts  form  an  excretory  apparatus.  They  open  into  the  allantois, 
and  in  some  cases  may  contain  urea,  uric  acid,  chlorids,  phos- 
phates, sulphates,  etc.  It  is  believed  this  is  an  indication  of  waste 
connected  with  tissue  metabolism.  With  regard  to  renal  activity 
in  late  fetal  life  there  has  been  considerable  difference  of  opinion. 
Fetal  urine  is  undoubtedly  frequently  found  in  the  liquor  amnii, 
but  not  in  such  quantities  as  to  indicate  that  it  is  an  important 
constituent.  When  an  imperforate  urethra  is  present  in  a  newborn 
child,  it  might  be  expected  that  distention  of  the  bladder  should 
always  be  present  if  renal  activity  is  marked  i)i  iitcro.  Occasion- 
ally this  is  found ;  but,  as  Joulin  has  shown,  in  a  large  percentage 
of  cases  there  is  no  distention.  Yet  urine  is  frequently  found  in 
the  fetal  bladder  at  birth  ;  in  breech  cases  the  fetus  may  urinate 
during  birth ;  premature  infants  may  have  urine  in  the  bladder ; 
methylen-blue  administered  to  the  mother  may  be  passed  by  the 
newborn  child.  The  fetal  urine  is  pale  and  of  low  specific  gravity 
(loio  or  less),  containing  a  small  quantity  of  urea  (0.15  per  cent., 
according  to  Helme),  abundant  uric  acid,  chlorids,  and  kreatinin. 
Frequently  albumin  is  found  in  it,  which  Flensburg  attributes  to 
the  increase  in  uric  acid.  Sometimes  it  contains  bilirubin  and 
indican,  and  certain  substances  which  may  be  administered  to  the 
mother.  Gusserow  gave  benzoate  of  soda  to  the  mother  and 
found  hippuric  acid  in  the  urine  of  the  newborn  fetus.  Schaller's 
experiments  are  important  in  this  connection.  He  administered 
phloridzin  to  pregnant  women  and  examined  the  fetal  urine  and 
liquor  amnii  at  various  periods.  This  drug  causes  sugar  in  the 
kidneys,  so  that  an  early  determination  of  the  renal  activity  may 
be  made.     Schaller's  conclusions  are  : 

1.  There  is  no  regular  secretion  and  periodic  excretion  of  urine 
by  the  fetus,  even  near  the  end  of  pregnancy. 

2.  Fetal  renal  activity  may  be  considered  to  begin  usually 
when  the  process  of  labor  induces  changes  in  the  fetal  circulation. 
But  even  during  labor  it  is  rare  that  the  fetus  urinates. 

3.  The  fetal  kidneys  functionate  much  more  slowly  than  those 
of  the  adult. 

It  is  certain  that  the  kidneys  are  capable  of  excreting  urine, 
though  the  function  very  often  is  not  exercised  until  the  time  of 
labor.     Ballantyne  states  that  it  may,  like  other  fetal  functions. 


86  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 

be  dispensed  with  if  the  placenta  acts  well.  With  regard  to  the 
emptying  of  the  bladder  into  the  amniotic  fluid,  he  says  that  there 
is  no  sufficient  proof  that  this  happens  constantly  or  even  fre- 
quently during  intra-uterine  life  ;  nor  is  it  probable  that  normally 
the  liquor  amnii  is  derived  mainly  from  the  fetal  urine. 

Glycogenic  Function. — Glycogen  is  found  in  many  tissues 
of  the  fetus,  even  in  early  pregnancy.  Though  it  is  believed  to 
represent  stored-up  nutritive  material,  its  exact  relationship  to 
metabolism  is  not  understood. 

Function  of  the  Nervous  System. — There  is  no  proof 
that  the  fetus  exhibits  purposeful  or  intelligent  action  while  in  the 
uterus.  The  gray  matter  is  not  well  developed,  and,  probably, 
fetal  movements  are  altogether  reflex.  Before  birth  some  parts 
only  of  the  afferent  tract  of  the  brain  are  myelinated ;  after  birth 
a  rapid  extension  takes  place. 

Fetal  movements  are  affected  by  various  maternal  conditions 
and  by  external  stimuli — /.  e.,  application  of  cold  to  the  abdomen, 
pressure  or  friction  applied  to  the  abdomen.  The  Rontgen  rays 
are  said  to  stimulate  them  ;  also  red  light,  strong  smells,  dreams, 
various  drugs,  etc.  The  fetus  possesses  cutaneous  sensibility, 
pinching  of  the  skin  setting  up  reflex  movements. 

Functions  of  the  Placenta. — In  describing  the  structure 
of  the  placenta  it  has  been  shown  to  be  entirely  an  organ  of  the 
chorion,  consisting  of  projections  of  the  latter,  termed  villi,  that 
are  attached  to  the  uterine  mucosa,  and  bathed  by  maternal  blood 
circulating  among  them. 

Comparatively  little  is  known  as  to  the  nature  of  the  inter- 
change of  materials  between  the  fetal  and  maternal  circulations 
through  the  medium  of  the  villi.  Reference  has  already  been 
made  to  the  respiratory  process  carried  on  by  them  during  preg- 
nancy. For  many  years  the  placenta  has  been  regarded  merely 
as  the  medium  through  which  nutritive  material  and  oxygen 
passed  from  the  mother  to  the  fetus,  and  the  effete  products  of 
fetal  metabolism  from  fetus  to  mother ;  it  was  considered  to  be  a 
kind  of  fine  sieve,  through  which  percolation  took  place,  or  a 
diffusion  membrane  that  favored  osmosis.  It  is  now  almost 
certain  that  the  transmission  of  substances  between  the  maternal 
and  fetal  blood  is  not  merely  a  matter  of  physics.  The  chorionic 
epithelium  is  now  believed  by  many  to  be  a  highly  differentiated 
tissue,  capable  of  carrying  on  complex  vital  processes,  possessing 
powers  of  selection,  elaboration,  and  even  digestion.  Cavazzani 
and  Levi,  for  example,  state  that  there  is  no  correspondence 
between  the  quantity  of  urea  in  the  maternal  and  fetal  blood,  that 
there  is  more  glucose  in  the  former  than  in  the  latter,  and  that 
the  density  of  the  fetal  blood  is  greater  than  that  of  the  maternal 
blood.  It  appears  that  there  are  considerable  variations  in  the 
transmission    of    substances    through    the    placenta    at    different 


FETAL    PHYSIOLOGY.  8/ 

periods  of  pregnancy.  Thus,  in  the  last  three  months  there  is  a 
great  increase  in  the  iron,  potash,  and  lime  stored  up  in  the  fetus. 
In  the  early  months  there  is  a  great  predominance  of  soda  over 
potash.  Phosphoric  acid  in  early  pregnancy  is  mainly  fixed  in 
the  fetus  in  nuclein  or  lecithin,  and  in  the  late  months  as  lime. 

Various  materials  may  be  stored  in  the  placenta.  Thus,  it 
undoubtedly  fixes  glycogen.  It  is  thought  that  albuminoid 
material  is  transmitted  as  soluble  peptones,  though  this  is  not 
definitely  known.  Many  drugs  introduced  into  the  maternal  cir- 
culation may  enter  the  fetal  blood^/.  e.,  strychnin,  ether,  iodin, 
chloroform,  quinin,  etc.  Bureau  reports  an  interesting  case  of  a 
woman  who  had  taken  large  doses  of  morphin  for  seven  years. 
During  her  pregnancy  she  took  about  fifteen  grains  daily.  When 
labor  took  place,  he  examined  the  blood  in  the  umbilical  cord 
and  found  the  drug  in  it.  Nicloux  has  shown  that  alcohol  given 
to  a  woman  an  hour  before  labor  can  be  found  in  the  umbilical 
vessels  at  birth.  There  has  been  some  question  as  to  the  possi- 
bility of  the  passage  of  maternal  leukocytes  through  the  walls  of 
the  villi  entering  the  fetal  circulation. 

Varaldo  states  that  there  are  more  leukocytes  in  the  umbilical 
vein  than  in  the  umbilical  arteries,  there  being,  on  the  average, 
considerably  more  per  cubic  millimeter  in  the  former  than  in  the 
latter,  and  that  more  of  them  contain  iodophilic  granules  in  the 
former  than  in  the  latter.  It  has,  therefore,  been  concluded  by 
several  that  leukocytes  normally  carry  substances  (possibly  nutri- 
ment) to  the  fetal  tissues.  This  has  not  been  proved,  however. 
In  maternal  leukocythemia  there  is  no  corresponding  increase  in 
white  corpuscles  in  the  fetal  blood. 

Various  maternal  diseases  are  transmitted  to  the  fetus  through 
the  placenta. 

The  placenta  acts  as  a  protective  barrier  against  the  invasion 
of  the  fetus  by  various  poisons.  It  is  more  eflficacious  against 
some  than  against  others.  Porak's  experiments  on  the  guinea- 
pig,  for  example,  show  that  in  this  animal  copper  passes  easily, 
arsenic  with  difficulty,  and  mercury  not  at  all,  the  poisons  being 
stored  to  a  greater  or  less  extent  in  the  placental  tissue.  With 
regard  to  micro-organisms  and  their  toxins  little  is  known.  Many 
microbes  are  able  to  pass  from  mother  tjo  fetus,  but  nothing  is 
known  as  to  the  conditions  associated  with  the  transit.  It  does 
not  appear  that  any  placental  lesion  is  necessary.  The  placenta 
appears  to  be  more  resistant  to  some  organisms  than  to  others. 
Thus,  it  is  clearly  established  that  tubercle  bacilli  rarely  pass 
through  it ;  indeed,  cases  of  Lehmann  and  others  prove  that 
though  tuberculosis  may  be  started  in  the  placental  tissue,  the 
fetus  may  be  free.  In  this  connection,  however,  it  must  be  noted 
that  sometimes  tubercle  bacilli  may  be  present  in  the  fetus,  though 
no  lesions  be  present,  inoculations  of  guinea-pigs  with  portions 


88  ANATOMY  AND   PHYSIOLOGY   OF  PREGNANCY. 

of  the  fetal  tissues  causing  tuberculosis.  It  seems  certain  that  in 
the  great  majority  of  cases  the  placenta  is  the  sole  route  by  which 
micro-organisms  and  toxins  reach  the  fetus.  It  is  possible  that 
they  may  pass  through  the  amnion  into  the  amniotic  fluid  and 
thence  enter  the  fetus,  but  this  is  probably  a  very  rare  mode  of 
infection.  Charrin  and  Duclert's  experiments  on  guinea-pigs 
suggest  that  the  passage  of  germs  through  the  placenta  is  helped 
or  retarded  by  vaiying  conditions  of  the  maternal  blood.  Thus, 
they  found  retardation  when  the  maternal  system  was  saturated 
with  corrosive  sublimate.  When  tuberculin,  alcohol,  acetate  of 
lead,  or  lactic  acid  was  present  the  passage  of  the  germs  seemed 
to  be  facilitated.  Neelow  has  experimented  on  pregnant  rabbits, 
and  states  that  non-pathogenic  organisms  cannot  pass  from  mother 
to  fetus. 

The  placenta  suffices  to  allow  the  fetus  to  grow  and  thrive  in 
many  diseased  conditions  or  malformations  incompatible  with 
health  or  life  in  the  adult.  Pathologic  conditions  affecting  the 
structure  and  function  of  the  placenta  endanger  the  life  of  the 
fetus.  In  many  maternal  diseases,  doubtless,  the  fetus  is  destroyed 
as  the  result  of  changes  in  the  placenta,  affecting  its  structure  or 
function,  produced  by  its  resistance  to  the  toxic  material  in  circu- 
lation. 

The  placenta  is  believed  b}'  man)^  to  produce  an  internal  secre- 
tion, and  there  has  been  considerable  speculation  as  to  the  role 
this  may  play  in  influencing  fetal  metabolism  and  as  a  destroyer 
of  toxic  agents  that  might  try  to  pass  from  the  maternal  blood 
to  the  fetus,  but  nothing  definite  is  known.  The  placenta  also 
acts  as  the  great  excretor}^  organ  for  the  fetus.  Savory  long  ago 
produced  tetanus  in  a  pregnant  cat  by  injecting  stiychnin  into  the 
fetus  in  utcro.  The  passage  of  other  drugs  has  been  similarly 
demonstrated  by  others.  Charrin  holds  that  toxins  placed  in  the 
fetus,  either  directly  or  by  the  spermatozoa  of  the  father,  may 
pass  to  the  mother  ;  this  might  explain  certain  cases  of  immuni- 
zation in  syphilis  (Colles's  law).  By  injecting  diphtheria  toxin 
into  the  fetus  in  ntcro  he  has  killed  the  mother  animal.  Guinard 
and  Hochwelker  have  shown  experimentally  that  the  passage  of 
drugs  from  the  fetus  to  the  mother  is  stopped  if  the  former  is 
killed,  and  that  if  the  fetus  be  injected  after  its  death  the  drug  is 
only  found  in  its  tissues.  Baron  and  Castaigne  have  found  that 
drugs  introduced  into  the  amniotic  fluid  are  also  transmitted  to 
the  maternal  tissues,  though  much  less  rapidly  than  w^hen  injected 
into  the  fetus.  If  the  latter  be  dead  the  substances  do  not  pass 
to  the  maternal  circulation.  Attempts  have  been  made  to  analyze 
the  placental  tissue.  It  is  stated  to  have  a  neutral  reaction  and 
to  contain  nearly  84  per  cent,  of  water.  Most  of  the  matters 
removed  by  extraction  are  albuminous,  only  a  small  part  being 
true  extractive.     In  the  ashes  there  is  a  large  quantity  of  phos- 


FETAL    PHYSIOLOGY.  89 

phorus,  an  excess  of  soda  over  potash,  and  much  lime.  Most 
of  the  phosphorus-containing  matters  are  easily  extracted  with 
water. 

I/iquor  Amnii. — Character — The  liquor  amnii  increases  in 
quantity  up  to  about  the  seventh  month,  and  afterward  decreases 
somewhat.  The  amount  varies  considerably  in  different  cases. 
It  bears  no  constant  relationship  to  the  weight  of  mother,  fetus, 
cord,  or  placenta.  In  an  eighth-month  pregnant  uterus  removed 
from  a  cadaver,  Barbour  and  Webster  found  that  the  space  occu- 
pied by  the  liquor  amnii  measured  somewhat  less  than  26  cubic 
inches.  At  term  the  quantity  measures  between  i  and  2  pints. 
In  early  pregnancy  the  fluid  is  usually  clear  and  pale ;  toward  the 
end  it  is  usually  turbid  and  variously  colored — /.  c,  green,  brown, 
blackish,  red,  according  to  its  constituents.  The  specific  gravity 
varies  from  iOD2  to  1028,  the  average  being  about  1008.  The 
reaction  is  slightly  alkaline  or  neutral.  It  contains  less  than  2 
per  cent,  of  solids,  consisting  of  urea  and  other  extractives,  various 
inorganic  salts,  a  slight  trace  of  albumin,  globulin,  and,  frequently, 
of  sugar.  Gillespie  has  found  traces  of  albumoses,  and  thinks 
they  may  be  produced  by  the  action  of  digestive  ferments  similar 
to  those  found  in  pleuritic  or  ascitic  effusions.  Mucin,  cholesterin, 
kreatin,  and  kreatinin  are  occasionally  found.  The  albumin  is 
less  at  the  end  than  in  early  pregnancy ;  the  urea  slightly  more 
abundant,  often  being  about  4  per  cent,  at  the  end  of  the  ninth 
month.  In  addition  the  hquor  usually  contains  lanugo,  vernix 
caseosa,  epidermis,  meconium,  and  intestinal  epithelium  in  varying 
quantities.  Veit  states  that  its  freezing-point  is  always  higher 
than  that  of  fetal  or  maternal  blood. 

Sources. — There  is  a  difference  of  opinion  as  to  whether  the 
liquor  amnii  is  derived  from  fetal  or  maternal  sources,  or  from 
both.  The  weight  of  evidence  favors  the  view  that  it  has  a  two- 
fold origin.  It  has  long  been  held  that  the  fetal  urine  is  an  im- 
portant constituent ;  but  it  is  interesting  to  note  that  during  the 
last  three  months  of  pregnancy,  when  the  excretion  of  fetal  urine 
might  be  expected  to  increase,  the  liquor  amnii  gradually  dimin- 
ishes in  quantity.  Moreover,  the  urea  in  the  liquor  amnii  is 
smaller  than  it  would  be  if  urine  were  continually  added  to  it. 
But  the  strongest  evidence  against  this  view  is  derived  from 
Schaller's  experiments,  to  which  I  have  already  referred.  Then, 
in  cases  of  obstruction  of  the  fetal  urinary  passage,  there  is  no 
necessary  accompanying  deficiency  of  liquor  amnii.  It  must, 
indeed,  be  concluded  that  the  fetal  urine  contributes  but  a  very 
small  part  to  the  amniotic  fluid.  By  some  it  is  believed  that  the 
latter  is  partly  derived  from  fetal  fluid  which  passes  through 
the  skin,  though  there  is  no  proof  that  this  takes  place  to  any 
appreciable  extent.  In  many  cases,  undoubtedly,  a  small  quantity 
is  derived  from    meconium  that  passes    from  the    bowel  of  the 


90  ANATOMY  AND   PHYSIOLOGY   OF  PREGNANCY. 

fetus,  though  this  is  of  very  little  significance ;  there  may  be 
abundant  liquor  amnii  when  the  anus  is  imperforate. 

Regarding  the  influence  of  the  fetal  vessels  in  the  cord  and 
placenta  in  producing  the  fluid,  nothing  definite  can  be  said.  It 
cannot  be  proved  that  they  do  not  play  a  part.  Neither  has  there 
been  a  satisfactory  estabHshment  of  the  view  that  the  fluid  is  de- 
rived from  maternal  vessels  by  a  transudation  through  the  mem- 
branes, although,  in  all  probability,  this  does  take  place  to  an  im- 
portant degree.  The  strongest  experimental  support  of  this  view 
is  that  furnished  by  Haidlen,  who  administered  iodin  to  a  pregnant 
woman,  in  whom  death  of  the  fetus  had  taken  place ;  the  drug 
was  found  in  the  amniotic  fluid. 

Uses. — The  liquor  amnii  furnishes  much  protection  to  the 
fetus.  It  insures  a  constant  pressure  and  temperature  during 
pregnancy  and  diminishes  the  risk  of  injury  from  without.  It 
allows  of  free  fetal  movements,  and  at  the  same  time  saves  the 
maternal  tissues  from  much  of  the  direct  impact  of  fetal  move- 
ments. In  labor,  especially  during  the  first  stage,  it  receives 
directly  the  pressure  due  to  the  uterine  contractions  and  causes  its 
equal  distribution,  the  fetus  itself  being  thereby  for  a  long  period 
protected.  When  the  membranes  rupture  the  escaping  amniotic 
fluid  seems  to  flush  out  and  cleanse  the  lower  genital  passage. 

According  to  Ballantyne  the  liquor  amnii  forms  the  chief  water 
supply  to  the  fetus.  It  is  absorbed  by  the  skin,  and  often  swal- 
lowed. He  also  thinks  that  some  nourishment  may  be  derived 
from  it,  as  Ahlfeld  has  strongly  insisted.  It  is  impossible  to  prove 
or  disprove  the  latter  statement.  Certainly  the  amount  of  nour- 
ishing material  in  the  fluid  is  ver)-  small. 

ANATOMIC  AND  PHYSIOLOGIC  CHANGES  IN  THE  MATERNAL 

SYSTEM. 

Uterus. — Shape  and  Size. — In  the  early  weeks  the  pregnant 
uterus  is  pear-shaped,  the  transverse  diameter  at  the  fundus  being 
wider  than  the  anteroposterior  diameter.  The  body  of  the  uterus 
is  not  infrequently  asymmetrical.  (See  p.  124.)  During  the  sec- 
ond, third,  and  fourth  months  the  corpus  uteri  becomes  somewhat 
spherical.  In  the  later  months  of  pregnancy  the  pyriform  shape 
is  again  assumed.  Webster  has  described  a  stage  that  appears 
to  be  intermediate.  In  the  cadaver  of  a  woman,  about  five  months 
pregnant,  studied  by  frozen  sections,  he  found  a  uterus  in  which 
the  body  was  neither  spherical  nor  pyriform  as  in  the  last  months 
of  pregnancy.  Its  longest  diameter  was  the  vertical  one,  and 
the  transverse  and  anteroposterior  diameters  of  the  lower  part  of 
the  body  were  greater  than  those  of  the  upper  part.  It  was, 
indeed,  somewhat  pear-shaped,  but  with  tlic  large  end  loiver- 
viost.  This  specimen  seems  to  indicate  that  the  uterus,  as 
found    at    the    midterm    of    pregnancy,    represents    mainly    the 


CHANGES  IN   THE   MATERNAL   SYSTEM. 


91 


lower  half  of  the  body  of  the  uterus  as  found  at  the  end  of 
pregnancy,  the  upper  portion  of  the  full-term  uterus  being  mainly 
an  upward  expansion  of  the  fundus  of  the  organ,  developing 
during  the  second  half  of  pregnancy.  This  intermediate  stage 
the  author  has  frequently  demonstrated  on  the  living  subject. 
Whether  or  not  it  is  present  in  every  case  cannot  be  stated. 


Fig.  56. — Vertical  mesial  section  of  pelvis  from  a  woman  who  died  of  pernicious 
vomiting  at  the  end  of  the  third  month  of  pregnancy.  A  considerable  portion  of  the 
decidua  reflexa  is  covered  by  the  placenta,  which  extends,  in  the  anterior  part  of  the 
uterus,  as  low  as  the  os  internum  :  a.  Uterine  wall,  to  which  the  serotinal  placenta  is 
attached;  b,  amniotic  cavity;  c,  fetus;  d,  serotinal  placenta;  e,  urine  in  bladder;/", 
space  between  decidua  vera  and  decidua  reflexa  ;  g,  junction  of  reflexa  and  serotina 
on  anterior  wall  of  uterus  ;  h,  decidua  reflexa  free  from  placenta  ;  /,  placenta  developed 
on  posterior  part  of  decidua  reflexa,  somewhat  degenerated  in  its  thinnest  portion  ; 
j,  OS  internum. 


The  shape  of  the  uterus  varies  considerably  according  to  the 
relationships  that  exist  between  it  and  surrounding  structures. 
Throughout  pregnancy  it  is  variously  moulded,  both  by  hard  and 
soft  structures.  This  is  best  demonstrated  by  studying  the  body 
after  it  has  been  frozen.     Sections  show  that,  in  the  second  half 


92 


ANATOMY  AND   PHYSIOLOGY   OF  PREGNANCY. 


of  pregnancy,  it  is  moulded  by  the  brim  of  the  pelvis,  the  bodies 
of  the  vertebrae,  by  distended  intestines,  etc.      It   may  also   be 


«--; 


Fig.  57. — Vertical  mesial  section.  Right  half.  Beginning  of  fifth  month  of  preg- 
nancy (reduced)  :  a,  Level  of  umbilicus;  h,  fundus  uteri;  c,  placenta;  d,  liquor  amnii ; 
c,  venous  sinus  ;  f,  cord  ;  g,  symphysis  ;  //,  uterovesical  pouch  ;  «',  bladder  ;  /,  promon- 
tory ;  k,  transition  in  thickness  of  uterine  wall;  /,  rectum  ;  7n,  arm  of  fetus;  n,  dermoid 
tumor  of  right  ovary  ;  o,  fetal  heart;  /,  pouch  of  Douglas ;  q,  rectum  ;  ;-,  os  internum  ; 
J,  OS  externum  ;  t,  anterior  forni.x. 


moulded    by  portions    of  the    fetus   that    press    against  it  from 
within.     In  a  thin  woman,  during  active  movements  of  the  fetus, 


CHANGES  IiV   THE   MATERNAL    SYSTEM.  93 

the  contour  of  the  uterine  wall  may  often  be  seen  to  change 
frequently. 

Measurements. — In  studying  the  measurements  of  the  uterus 
it  must  be  remembered  that  there  are  normal  variations,  such  as 
are  found  in  other  organs  of  the  body.  Then,  those  due  to  altera- 
tions in  shape  produced  by  surrounding  structures  must  be  taken 
into  account. 

The  diameters  can  be  most  accurately  measured  in  the  frozen 
cadaver,  not  in  the  living  subject,  in  whom  the  outer  surface  of 
the  pregnant  organ  is  so  hard  to  define.  In  the  early  part  of  the 
fourth  month  Webster  found  the  vertical  diameter  from  the  os 
internum  to  the  outside  of  the  fundus  to  be  3^  in.  In  the  be- 
ginning of  the  fifth  month  he  found  it  to  be  6  in.  In  Bar- 
bour and  Webster's  eighth-month  specimen  it  measured  about 
9  in.  At  full  time  the  vertical  diameter,  as  measured  in 
frozen  sections  of  Braune's,  Waldeyer's,  and  Barbour's,  varies 
from  about  9j  to  10  in.  The  widest  anteroposterior  diameter 
measures  5^  to  6  in. ;  the  greatest  transverse  diameter  between 
8^  and  9  in. ;  the  greatest  anteroposterior  circumference  24  to 
26\  in." 

Position. — Variations  are  found  in  the  position  of  the  pregnant 
uterus  just  as  in  the  case  of  the  non-pregnant  organ.  These  may 
be  congenital  or  may  be  due  to  acquired  causes.  Thus,  the  uterus 
may  be  symmetrically  placed,  its  long  vertical  axis  being  in  the 
middle  line  of  the  body ;  this  is  more  common  in  primiparae. 
Frequently  the  whole  organ  is  placed  nearer  one  side  of  the  pelvis 
than  of  the  other.  In  many  cases  the  long  axis  is  oblique  to  that 
of  the  body.  This  is  most  marked  where  deviation  is  caused  by 
old  inflammatory  conditions,  tum.ors,  distention  of  the  bladder  or 
intestine.  Webster  has  recently  investigated  a  specimen  in  which 
marked  obliquity  and  elevation  of  the  sixth-month  pregnant  uterus 
were  caused  by  an  accumulation  of  urine  in  the  bladder,  mainly  in 
one  half  of  the  pelvis.  Of  all  the  deviations  found,  that  of  the 
fundus  toward  the  right  is  the  most  frequent ;  this  is  in  corre- 
spondence with  what  is  found  in  the  non-pregnant  state. 

It  is  often  stated  that  in  the  early  weeks  of  pregnancy  the 
uterus,  as  a  whole,  sinks  down  in  the  pelvis.  That  the  enlarging 
body,  in  the  erect  posture,  rests  on  a  greater  area  of  the  bladder 
and  presses  more  heavily  upon  it  is  certain,  but  there  is  no  satis- 
factory proof  that  the  cervix  is  appreciably  lowered  if  the  woman 
be  healthy  and  uninjured.  It  must  be  remembered  that  in  normal 
nulliparae  there  are  variations  in  the  situation  of  the  uterus  in  the 
pelvis,  and  also  that  it  lies  at  a  lower  level  in  women  who  have 
born  a  number  of  children.  Though  the  difficulty  of  establish- 
ing accurate  topographic  relationships  by  clinical  means  is  great, 
it  may  readily  be  granted  that,  owing  to  the  softening  of  the  tis- 
sues of  the  pelvic  floor  and  the  increasing  weight  of  the  uterus, 


94  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 

there  may  be  a  very  slight  descent  of  the  organ,  as  a  whole,  in 
the  first  three  months. 

The  normal  anteversion  and  anteflexion  tend  to  become  more 
pronounced  during  the  early  weeks  ;  as  the  uterus  grows  upward 
into  the  abdomen  these  characteristics  become  less  marked.  During 
the  late  weeks  there  may  be  slight  descent  of  the  organ,  as  a  whole  ; 
but  more  noticeable  is  the  tendency  to  increased  anteversion,  the 
fundus  falling  downward  and  forward.    The  most  marked  changes 


Fig.  58. — Vertical  mesial  section  of  a  multipara  who  died  in  the  eighth  month  of  preg- 
nancy.    The  fetus  and  liquor  amnii  have  been  removed. 

in  the  position  of  the  fundus  are  found  in  multiparae  with  a  relaxed 
abdominal  wall,  especially  if  there  be  marked  separation  of  the 
recti.  When  the  latter  diastasis  exists  in  an  extreme  degree  the 
uterus  may  fall  forward  and  bulge  between  the  muscles  when  the 
patient  is  erect. 

It  is  frequently  stated  that  the  uterus  rotates  on  its  long  axis 
as  it  grows  in  pregnancy,  the  movement  being  either  toward  the 
right  or  left;  most  frequently  in  the  former  direction,  so  that  the 


CHANGES  IN  THE  MATERNAL   SYSTEM. 


95 


left  border  is  moved  forward  in  the  pelvis.  In  special  investiga- 
tions made  to  determine  the  accuracy  of  this  view,  Webster  has 
shown  that  there  is  no  proof  that  rotation  characterizes  the  growth 
of  the  gravid  uterus. 

Rotation,  undoubtedly,  is  occasionally  found,  but  we  cannot 
speak  with  certainty  regarding  the  frequency  of  its  occurrence. 


./ — 

-      A 

h 

.\ 

Fig.  59. — Vertical  mesial  section  of  a  multipara  who  died  of  tuberculosis  in  the 
eighth  month  of  pregnancy.  The  body  was  frozen  (Barbour  and  Webster)  :  a,  Venous 
sinuses;  d,  placenta;  c,  umbilical  cord;  d,  vertebras  of  fetus;  e,  uterovesical  reflection 
of  peritoneum_ ;  /  symphysis  pubis;  ^,  bladder;  A,  vagina;  i.  liquor  amnii ;  /,  head  of 
child;  /?•,  umbilical  cord;  /,  left  lower  leg;  tn,  promontory  of  sacrum;  n,  cervix;  0, 
pouch  of  Douglas  ;  /,  rectum. 

Clinically  it  is  impossible,  save  very  rarely,  to  estimate  it.  The 
outlines  of  the  soft  and  easily  moulded  uterine  bag  cannot  be 
defined,  nor  can  the  landmarks  necessary  to  the  exact  determina- 
tion of  rotation  be  made  out.  No  doubt,  in  some  cases,  condi- 
tions described  as  rotation  have  been  really  only  the  moulding  of 
the  uterus  on  the  fetus  by  the  examining  hand  or  against  sur- 
rounding structures.     Again,  rotation  has  been  described  where 


96 


ANATOMY  AXD   PHYSIOLOGY  OF  PREGAANCY. 


it  has  not  been  true  or  inherent,  but  only  accidental,  due  to  dis- 
placement by  distended  bowel  or  bladder,  or  to  that  caused  by 
old  adhesions  or  cicatrices. 

In  many  cases  the  rotation  found  in  pregnane}-  is  only  the 
continuance  of  the  condition  that  was  present  in  the  non-preg- 
nant state.  \\  e  know^  that  rotation  is  frequently  present  in  the 
normal  nullipara,  and  it  is  not  surprising  that  it  is  also  found  in 
pregnane}'. 

Some  authors  have  insisted  that  rotation  exerts  an  important 
influence  in  modifying  the  position  of  the  fetus.  Such  a  state- 
ment is  entirely  speculative  and  is  incompatible  with  our  present 
knowledge  of  the  anatomy  of  pregnancy. 

Volume. — Webster    measured    the    surface  area   of  the   wall 


Fig.  6o. — Cast  of  the  amniotic  cavity  in  the  eighth  month  of  pregnancy.  The  body 
was  frozen  (Barbour  and  Webster)  :  .•^,' Anterior  surface  ;  .g,  right  lateral  surface.  The 
shaded  area  in  (A)  is  the  placental  area;  the  bend  on  the  posterior  wall  in  {B)  corre- 
sponds to  the  projection  of  the  sacral  promontory. 

of  the  amniotic  cavity  of  the  uterus  in  the  beginning  of  the  fifth 
month  of  pregnane}-  and  found  it  to  be  65  sq.  in.  The  cubic 
contents  measured  610  c.c.  In  Barbour  and  Webster's  eighth- 
month  case  the  area  of  the  wall  was  147  sq.  in.,  and  the  capacity 
of  the  amniotic  cavity  about  158  cu.  in.  At  full  term,  according 
to  Barbour,  the  area  of  the  wall  is  about  200  sq.  in.  Krause  calcu- 
lates that  the  uterine  cavity  at  this  period  is  519  times  greater 
than  in  the  virgin  state. 

Weight. — The  empty  full-time  uterus  weighs  from  24  to  28 
oz.  In  the  nullipara  it  weighs  about  i  oz.,  and  in  the  multipara 
about  i^  oz. 

Divisions  of  the  Uterine  Wall. — In  the  pregnant  uterus  three 
parts  are   ordinarily  considered — cervix,  lower  uterine  segment, 


CHANGES  IN   THE   MATERNAL    SYSTEM. 


97 


upper  uterine  segment.  The  latter  two  parts  together  make  up 
the  body  of  the  uterus.  This  subdivision  is  not  made  in  describ- 
ing the  non-pregnant  uterus. 

The  distinction  between  the  three  parts  is  best  made  out  when 
sections  of  the  frozen  cadaver  are  made.  To  the  naked  eye  the 
difference  between  the  upper  and  lower  segments  is  merely  one 
of  thickness.  A  well-marked  illustration  is  found  in  Webster's 
section  of  a  fifth-month  pregnancy.  There  has  been  much  dis- 
cussion in  recent  years  as  to  the  na- 
ture and  relationships  of  the  various  ^^  .^-j^^^-^// 
divisions,  especially  of  the  lower  uter-  ^^ 
ine  segment  and  cervix.  The  follow- 
ing description  is  based  upon  ana-  v  "''^v  "\^  %"< 
tomic  investigations  :  The  cervix  be-  ^'^  ti 
comes  softened  and  congested  during 
pregnancy,  being  slightly  enlarged  in 
its  transverse  diameters  during  the  ...,., 
early  months.  It  changes  very  little 
during  pregnancy.  There  is  no  ana-  \'  Wl 
tomic    shortening.       Descriptions    of      ^,     ^       _     .     '       ^    , 

,  .  ,  °  ..    .  ^ .  Fig.  6i. — Cervix  at  end  of  preg- 

snortenmg    based    on    clmical    exam-  nancy  (Waideyer). 

ination    are  entirely   unreliable ;    it  is 

easy  to  err,  so  soft  and  compressible  is  the  cervix  in  many  cases. 
Frozen  sections  have  established  the  fact  that,  taking  individual 
variations  into  consideration,  the  cervix  is  nearly  as  large  at  the 
end  as  at  the  beginning  of  pregnancy.  Barbour  gives  the  follow- 
ing table  of  measurements  : 

Month.  Number  of  Average  length 

cases.  of  cervix. 

Fourth 5  4.6  cm. 

Fifth     .    -^ 3  4.3    " 

Sixth  and  Seventh 10  4.0    " 

Kighth 3  4.5    " 

Ninth 4  3-5    " 

Tenth 12  ,                  3.6    " 

The  slight  shortening  of  the  late  weeks  is  not  a  true  inherent 
change  in  the  tissues  of  the  cervix,  but  a  mechanical  alteration, 
largely  due  to  the  weight  of  the  growing  uterine  body  pressing 
the  softened  cervix  downward  against  the  subjacent  tissues.  In 
many  cases,  also,  another  factor  is  present — viz.,  widening  of  the 
cervical  canal  in  the  late  weeks.  In  primiparae  this  is  usually 
marked  only  in  the  lower  part  of  the  canal  immediately  before 
labor ;  in  multiparae  some  weeks  beforehand ;  frequently  the 
whole  canal  widens  so  that  the  presenting  part  of  the  fetus  may 
be  felt  through  the  os  internum.  It  is  very  evident  that  such 
relaxation  of  the  cervix  and  widening  of  the  canal  must  be  accom- 
panied with  slight  diminution  of  the  vertical  diameter.  The  ex- 
planation of  cervical  dilatation  and  of  the  variations  found,  in  many 
7 


98  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 

cases  of  advanced  pregnancy  are  unknown.  It  has  been  sug- 
gested that  the  painless  uterine  contractions  cause  it.  As  well- 
marked  degrees  are  found  in  multiparae,  an  important  factor  is 
undoubtedly  the  weakened  structure  of  the  cervix.  The  weight 
of  the  uterine  contents  in  the  erect  posture  may  mechanically 
exercise  some  influence.  But  an  important  factor  is  the  increased 
serous  infiltration  of  the  cervical  tissues  during  the  last  weeks, 
due  to  increased  congestion  of  the  vessels  accompanying  the 
interference  with  the  circulation  caused  by  the  sinking  of  the 
uterus. 

The  old  view  that  the  cervix  is  shortened  in  pregnancy  because 
it  is  taken  up  into  the  lower  part  of  the  body  must  be  abandoned. 
There  is  no  such  process.  The  lower  uterine  segment  belongs 
entirely  to  the  body  and  the  cervix  contributes  nothing  to  it. 
On  section  the  wall  of  the  cervix  has  a  felted  texture,  the  spaces 
between  the  bundles  of  tissue  being  larger  than  in  the  non-preg- 
nant state.  Indeed,  any  increase  in  thickness  may  alone  be 
accounted  for  by  the  increased  fluid  in  these  spaces.  It  is  easily 
distinguished  from  the  lower  uterine  segment,  because  the  latter 
has  much  less  white  and  elastic  connective  tissue  and  a  greater 
proportion  of  muscle,  which  is  arranged  in  a  series  of  plates 
parallel  to  the  long  axis  of  the  wall.  The  transition  between  the 
two  arrangements  is  fairly  sharp  and  distinct.  The  cervical 
glands  are  considerably  enlarged  and  secrete  abundant  mucus  ; 
the  latter  forms  a  large  plug  that  fills  the  canal.  There  is  no 
sharp  transition  between  the  cervical  mucosa  and  that  lining  the 
lower  uterine  segment,  as  is  the  case  in  the  non-pregnant  uterus. 
The  relation  of  the  membranes  is  no  guide,  for  while  the\'  may 
often  be  adherent  down  to  the  upper  end  of  the  cervix,  they  are 
frequently  loosely  attached  or  quite  free  above  it  for  some  distance. 

Many  variations  are  found  in  the  distribution  of  the  decidual 
cells  in  the  mucosa  above  the  cervix.  Here  they  are  often  scanty 
or  degenerated  in  the  late  months.  Usually  these  are  not  found 
in  the  cervical  mucosa,  whose  connective-tissue  cells  are  small 
and  numerous,  but  occasionally  a  few  decidual  cells  may  be  found 
below  the  level  of  the  os  internum. 

Body=waU. — The  differentiation  of  the  lower  from  the  upper 
uterine  segment  is  not  constantly  or  definitely  marked.  Sections 
of  frozen  cadavers  show  that  many  variations  are  found.  It  is 
not  known  when  the  differentiation  begins.  Sections  of  the  frozen 
body  made  in  early  pregnancy  show  that  during  the  first  three 
months  the  wall  is  not  thinner  above  the  cervix  than  elsewhere. 
Webster's  fourth-month  specimen  shows  a  slight  difference  both 
anteriorly  and  posteriorly;  Waldeyer's  later  fourth-month  speci- 
men has  a  thin  wall  posteriorly  as  high  as  the  fundus,  whereas 
the  whole  anterior  wall  is  thicker  near  the  cervix  than  at  a  higher 
level.     In    Webster's    fifth-month    case    there    is    a  well-marked 


CHANGES  IN   TJIE   MATERNAL    SYSTEM. 


99 


differentiation  into  upper  and  lower  segments,  much  better  marked 
than  in  most  published  cases. 

In  the  second  half  of  pregnancy  differentiation  is  much  more 
frequently  noticed,  but  there  are  many  variations.  Thus,  in  a  full- 
time  uterus  described  by  Bayer  the  lower  uterine  segment  meas- 
ured 3|-  in.,  and  in  another  ^-^-^  in. ;  in  2  cases  of  Hofmeier's  it 


Fig.  62. — Injected  veins  and  arteries  of  pregnant  uterus  (from  a  preparation  by 
Hyrtl)  (Heitzmann) :  a,  Uterine  artery  ;  b,  uterine  vein  ;  c,  vaginal  branches  of  uterine 
artery  ;  d,  ovarian  artery  ;  e,  ovarian  vein  ;  f,  vaginal  plexus. 


was  about  2|  in.  In  2  eighth-month  specimens  I  found  the  differ- 
entiation so  slight  that  it  was  impossible  to  make  any  accurate 
measurements. 

In  most  full-time  cases  the  lower  part  of  the  anterior  wall  of 
the  body  is  somewhat  thinned,  varying  in  different  cases.  In 
Braune's,  Waldeyer's,  and  Braune  and  Zweifel's  specimens  it  is 
about    one-third    the    thickness    of  the    upper    uterine  segment. 


lOO 


ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 


Posteriorly  the  corresponding  part   of  the  wall  is  not  thinned, 
being  as  thick  or  thicker  than  the  upper  uterine  segment. 

In  some  the  peritoneum  is  loosely  attached  over  the  lower 
segment  of  the  anterior  uterine  wall,  being  firmly  united  to  it 
above.  This  relationship  is  not  always  present,  many  variations 
being  found  at  different  periods  of  pregnancy.     A  more  constant 


Fig.  63. — Vertical  mesial  section  of  a  woman  who  died  in  the  sixth  month  of  preg- 
nancy. The  uterus  was  much  displaced  upward  and  to  the  left  as  a  result  of  the  dis- 
tention of  the  bladder  by  a  considerable  quantity  of  urine.  The  irregular  outline  of 
the  uterine  wall  is  mainly  due  to  manipulations  of  the  body  before  freezing :  a,  Sym- 
physis pubis  ;  b,  promontory  ;  c,  uterine  wall ;  d,  fetus  ;  e,  amniotic  fluid  ;  f,  cavity  of 
bladder  containing  urine  ;  t{,  vagina;  h,  rectum. 


characteristic  of  the  lower  segment  is  the  arrangement  of  the 
muscular  tissue  into  a  series  of  easily  separable  plates,  lying  in 
the  long  axis  of  the  uterus.  This  peculiarity  may  exist  although 
the  lower  segment  may  not  differ  in  thickness  from  the  upper 
segment.  The  extent  to  which  it  may  be  found  varies  ;  in  the 
advanced  months  it  is  usually  between  i  and  3  in.  Close  to  the 
cervix  the  plates  spread  out  and  blend  with  the  felted  texture  of 


CHANGES   IN   THE   MATERNAL    SYSTEM. 


lOI 


the  cervix.     The  relationship  of  the  mucosa  hning  the  lower  seg- 
ment to  that  of  the  cervix  I  have  already  described. 

As  to  the  nature  of  the  lower  segment  there  can  be  no  doubt 
that  it  is  the  lower  part  of  the  uterine  body,  being  in  no  degree 
derived  from  the  cervix.  As  found  at  the  end  of  pregnancy  it 
represents  that  which  forms  almost  the  whole  uterus  at  the  fourth 
month  ;  the  increase  in  the  organ  after  this  period  taking  place 
mainly  in  its  upper  portion.  The  thinning  of  the  lower  segment 
is  doubtless  related,  as  Barbour  has  suggested,  to  the  pressure  of 
the  uterine  contents,  variations  being  probably  mainly  due  to  the 
consistence  of  the  segment  and  to  the  amount  of  pressure.  In 
the  erect  posture  the  contents  press  more  directly  upon  the  ante- 


FlG.  64. — a;  Isolated  muscle  elements  of  the  non-pregnant  uterus  ;   B,  cells  from  the 
organ  shortly  after  delivery  (Sappey). 


rior  than  upon  the  posterior  wall ;  this  may  explain  why  the 
former  is  more  frequently  thinned  than  the  latter.  As  to  the 
upper  uterine  segment,  it  must  be  noted  that  it  is  not  usually  of 
uniform  thickness,  that  part  to  which  the  placenta  is  attached 
being  thinner  than  the  rest.  The  statement  that  a  large  sinus 
usually  marks  the  junction  of  the  lower  and  upper  segments  is 
not  correct.  There  is  no  definite  or  constant  line  of  demarcation 
between  the  segments  in  pregnancy. 

Changes  in  the  Musculature. — The  physiologic  changes  in 
the  musculature  of  the  body  consist  in  a  hypertrophy  of  pre- 
existing fibers  ;  they  increase  fifty  to  eighty  times  in  length  and 
two  to  three  times  in  thickness.     New  fibers  are  also  developed 


I02  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 

from    embryonic    cells   which   are    present   in   the   non-pregnant 
uterus.     The  largest  fibers  may  be  as  large  as  ^^  in.  in  length. 

The  arrangement  of  the  muscular  bundles  is  complicated. 
They  may  be  divided  into  three  sets  : 

1.  A  thin  outer  layer,  covering  the  uterus  anteriorly  and 
posteriorly,  consisting  of  longitudinal  and  transverse  bands  which 
extend  into  the  various  uterine  ligaments. 

2.  A  thick  middle  layer,  forming  the  main  thickness  of  the 
uterine  wall,  made  up  of  irregular  bands  of  fibers. 

3.  A  very  thin  inner  layer,  whose  fibers  run  transversely  ;  it 
forms  concentric  bands  around  the  inner  end  of  the  Fallopian 
tubes  and  os  internum,  the  latter  being  very  strong. 

In  the  lower  uterine  segment  very  little  of  the  arrangement  of 
the  middle  layer  is  found.  In  the  cervix  the  musculature  is  an 
irregular,  felted  mass.  A  concentric  band  may  often  be  traced 
around  the  os  externum. 

Blood=vessels. — The  arteries  become  increased  in  length  and 
thickness  and  are  more  tortuous  during  pregnancy.  During  the 
late  months  diminution  of  the  lumen  is  frequently  observed,  due 
to  a  thickening  of  the  intima  or  outer  part  of  the  wall. 

The  veins  also  increase  greatly.  Their  walls  are  very  thin, 
being  supported  by  the  surrounding  uterine  musculature.  Thick- 
ening of  the  wall  is  also  found  in  different  vessels  toward  the  end 
of  pregnancy,  and  thrombosis  is  often  noted.  There  is  also  great 
increase  in  the  lymphatics  and  nerves  of  the  uterus.  The  ganglia 
near  the  cervix  become  enlarged,  and  the  nervous  irritability  of 
the  whole  uterus  is  intensified. 

Pelvic  Floor. — During  pregnancy  there  is  considerable  soften- 
ing of  the  tissues  of  the  floor,  accompanying  an  increased  quantity 
of  blood  circulating  through  them.  This  is  of  importance  in  facili- 
tating the  stretching  of  tissues  occasioned  by  parturition.  As 
regards  the  disposition  of  the  floor  as  a  whole,  the  chief  change 
in  pregnancy  is  that  caused  by  the  increased  intra-abdominal 
pressure. 

Measurements  made  upon  the  frozen  cadaver  show  that  the 
floor  is  somewhat  bulged  downward  during  the  second  half  of 
oregnancy.  This  is  evident  from  the  increased  pelvic-floor  pro- 
jection as  well  as  the  skin  distance  from  the  coccyx  to  the  sym- 
physis. The  base  of  the  bladder,  urethral  orifice,  cervix,  and 
bottom  of  the  uterovesical  pouch  are  lower  than  in  the  nulliparous 
condition.  Considerable  variations  are  found  in  normal  cases,  due 
to  individual  peculiarities  of  shape,  to  different  degrees  of  relaxa- 
tion in  the  tissues,  and  to  differences  in  intra-abdominal  pressure. 
Thus,  in  a  primipara  during  the  last  weeks  of  gestation  the  cervix 
is  usually  at  a  lower  level  than  in  a  multipara.  This  is  due  to 
the  greater  resistance  of  the  abdominal  parietes  to  the  upward 
development  of  the  uterus  in  the  former.     The  bladder  is  usually 


CHANGES  IN   THE   MATERNAL    SYSTEM. 


IQ- 


entirely  within  the  pelvis  when  empty,  and  is  found  at  different 
levels.  As  it  becomes  distended  it  may  rise  above  the  brim,  but 
as  pregnancy  advances  upward  expansion  is  relatively  less  marked 
than  lateral  expansion,  which  may  be  equal  on  each  side  of  the 
middle  line,  or  greater  on  one  side  than  on  the  other.  Through- 
out a  considerable  period  of  pregnancy  the  uterus  is  elevated  by 
the  well-filled  bladder.  In  a  sixth-month  specimen  studied  by 
Webster,  such  displacement  of  the  uterus  is  well  shown.  The 
more  pregnancy  is  advanced  the  less  the  uterus  is  disturbed, 
and  the  bladder  is  forced  to  distend  more  transversely.  When 
the  viscus  is  distended  with  urine  its  upper  surface  is  concave,  as 
a  result  of  the  pressure  of  the  anterior  uterine  wall. 

Pelvic  Peritoneum. — It  has  been  widely  taught  that  the  entire 
peritoneum  in  pregnancy  is  elevated  by  the  upward  growth  of  the 
uterus.  Recent  investigations  of  frozen  cadavers,  in  which  undis- 
turbed relationships  can  be  studied,  prove  that  this  teaching  is 
only   partially  true.      They   show   clearly    that   the   peritoneum 


Ureter. —  f 
Right  sacra-iliac— f  - 
joint.  — V^- 

Iliac  vessels.      \ 


Rectum.' 

Cervix  J 

Pouch  of  Douglas.' 


Left  ilio-pectineal 

eminence . 
Cavity  of  uterus. 
— Acetabulum. 
Uterine  luall. 
Ureter. 
''~' Large  venous 
sitiuses. 
■  Coccyx. 


Fig.  65. — Vertical  oblique  section  of  pelvis  of  eighth-month  pregnancy.     The  fetus  has 
been  removed  from  the  uterus  (Barbour  and  Webster). 


covering  the  uterus  increases  along  with  its  musculature,  and  that 
the  stripping  of  the  peritoneum  from  the  posterior  part  of  the 
upper  surface  of  the  bladder  occurs  with  no  uniformity  or  regu- 
larity. This  stripping  is  generally  attributed  to  elevation  by  the 
growing  uterus,  but  as  the  growth  changes  in  the  organ  during 
the  second  half  of  pregnancy  affect  chiefly  its  upper  part,  it  is 
difficult  to  understand  how  they  can  affect  the  peritoneal  rela- 
tions of  the  anterior  and  posterior  pouches.  It  seems,  rather,  that 
the  bladder  is  stripped  away  from  the  peritoneum  by  the  sinking 
of  the  pelvic  floor,  though  the  former  may  be  the  explanation  in 
some  cases.  Owing  to  the  very  delicate  loose  connective  tissue 
joining  the  bladder  and  peritoneum,  the  latter  does  not  follow  the 
posterior  part  of  the  former  in  its  downward  descent.  Usually 
the  bulging  of  the  floor  is  most  marked  near  the  end  of  preg- 
nancy. Waldeyer's  and  Braune's  sections  show  a  great  part  of 
the  bladder  uncovered.  In  Barbour  and  Webster's  eighth-month 
case,  where  the  bladder  is  not  so  low,  there  is  scarcely  any  strip- 


I04 


AJK'^TOA/Y  AND   PHYSIOLOGY  OF  PREGNANCY. 


ping  of  the  peritoneum.  The  variations  that  are  found  are  prob- 
ably also  due  to  the  different  degrees  to  which  the  peritoneum  is 
folded  in  the  uterovesical  poucn.  The  extent  of  the  stripping 
must  depend  upon  the  amount  of  unfolding  that  takes  place. 

As  regards  the  pouch  of  Douglas,  there  is  no  elevation  of  its 
central  portion  throughout  the  whole  of  pregnancy. 

The  lateral  relationships  of  the  pelvic  peritoneum  have  been 
chiefly  studied  by  Polk  and  Barbour.  They  have  shown  that  the 
base  of  the  broad  ligament  is  considerably  elevated  by  the  ex- 
panding uterus,  a  large  area  on  each  side  being  thus  uncovered. 
In  Barbour  and  Webster's  eighth-month  specimen  the  anterior 


Symphysis  pubu 


Fig.  66. — Full-time  pregnancy.     Reconstruction  from  frozen  sections. 

anterior  position  (Braunej. 


Right  occipito- 


layer  of  the  ligament  descended  below  the  brim  as  far  as  the 
center  of  the  acetabulum.  When  the  uterus  was  pulled  genth' 
away  from  the  bone  at  the  brim  level  the  layers  of  each  ligament 
were  i^  in.  apart,  although,  in  the  undisturbed  condition  of  parts, 
they  were  so  disposed  as  almost  to  meet,  being  folded  upon  the 
cellular  tissue  between. 

In  a  full-time  case  in  which  labor  had  just  begun  the  highest 
lateral  point  of  attachment  of  the  broad  ligament  was  on  the  right 
.side,  where  it  was  ^  in.  below  the  middle  of  the  iliac  crest ;  on 
the  left  side  ^  in.  lower.  The  lowest  point  on  both  sides  was 
about  the  level  of  the  center  of  the  acetabulum,  the  layers  being 


CHANGES   IN   THE   MATERNAL    SYSTEM.  I05 

Y'g  in.  apart  on  the  right  side  and  i  in.  on  the  left.  The  utero- 
sacral  ligaments  extended  from  near  the  brim  posteriorly  down- 
ward and  forward,  to  be  attached  to  the  uterus  i^  in.  below  the 
level  of  their  posterior  ends.  The  round  ligaments  increase 
greatly  in  length ;  at  full  time  they  extend  from  the  uterus  down- 
ward and  inward  almost  vertically,  curving  forward  at  their  lower 
ends  toward  the  internal  abdominal  rings.  Where  they  turn  for- 
ward they  may  often  make  a  sharp  bend,  each  ligament  being 
folded  on  itself.  The  round  ligaments  are  not  tense  in  pregnancy 
unless  the  uterus  is  so  displaced  upward  as  to  stretch  them  some- 
what. 

The  Fallopian  tubes  at  full  time  are  found  in  different  posi- 
tions. Their  outer  ends  are  generally  packed  between  the  uterus 
and  the  upper  part  of  the  iliac  fossae.  The  ovaries  also  vary  in 
their  relationships.  Like  the  tubes,  they  are  capable  of  a  con- 
siderable range  of  movement,  owing  to  the  mobility  of  the  upper 
parts  of  the  broad  ligament,  and  they  may  thus  vary  in  position 
within  certain  limits,  apart  from  movements  of  the  pregnant  uterus. 

Relationships  of  thi  Uterus. — The  pregnant  uterus  is  plastic, 
being  readily  moulded  by  structures  firmer  than  itself  with  which 
it  comes  in  contact.  Normally,  in  the  advanced  stages,  it  shows 
the  indentation  of  the  vertebral  bodies  and  posterior  half  of  the 
pelvic  brim.  The  bowel,  tense  with  gas  or  feces,  easily  makes  an 
impression  upon  it. 

The  more  tense  the  abdominal  wall  the  less  room  there  is 
for  expansion  of  the  uterus,  which  consequently  is  pressed  more 
backward  against  the  spine.  In  a  primipara,  therefore,  the  pressure 
is  always  greater  than  in  a  multipara.  Where  the  abdominal  wall 
is  lax  the  fundus  is  directed  somewhat  forward  when  the  woman 
is  in  the  erect  posture.  When  there  is  marked  separation  of  the 
recti  muscles  this  is  found  in  a  marked  degree. 

In  the  first  three  months  of  pregnancy  the  uterus  lies  entirely 
within  the  pelvic  cavity.  As  it  rises  upward  the  anterior  wall 
comes  into  direct  contact  with  the  anterior  abdominal  wall,  the 
intestines  being  elevated ;  at  full  time  they  are  in  contact  up  to  a 
varying  distance  above  the  umbilicus.  Above  this  they  are  sepa- 
rated by  intestines ;  usually  the  latter  dip  very  slightly  below  the 
level  of  the  fundus  in  front  of  the  uterus.  They  lie  mainly  be- 
tween the  fundus  and  the  liver,  and  between  the  posterior  abdom- 
inal and  uterine  walls  on  each  side  of  the  spine  for  a  short  distance 
only  below  the  fundus.  Occasionally,  in  conditions  producing 
marked  tympanites,  the  bowels  may  descend  in  front  of  the  uterus  ; 
or  they  may  exist  there  throughout  gestation,  as  the  result  of  old 
adhesions.  Sometimes  the  omentum  alone  may  lie  between  the 
uterus  and  abdominal  wall  below  the  level  of  the  navel,  even  in 
advanced  gestation,  though  ordinarily  it  lies  in  the  region  of  the 
fundus. 


I06  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 

The  highest  point  of  the  diaphragm  is  elevated  from  i  to  2  in. 
at  full  term  ;  in  a  case  of  Barbour's  it  was  opposite  the  cartilage 
joining  the  eighth  and  ninth  dorsal  vertebrae.  The  liver,  there- 
fore, is  considerably  elevated.  In  the  pelvis,  besides  the  rectum,  a 
loop  of  sigmoid  flexure  may  be  found  in  the  pouch  of  Douglas. 
Very  rarely  a  coil  of  the  ileum  may  be  found  there. 

As  regards  the  relationship  of  the  ureters,  it  is  generally  be- 
lieved that  they  are  so  protected  by  their  position  in  the  declivit}' 
on  each  side  of  the  spine  that  the  uterus  does  not  press  directly 
upon  them.  Frozen  sections,  however,  prove  that  the  pregnant 
uterus  may  mould  itself  closely  against  the  pelvic  brim  and  sides 
of  the  vertebral  bodies,  and  it  is  not  unlikely  that  this  exercises 
some  pressure  upon  the  ureters,  especially  if  the  uterus  be  very 
large,  the  pelvis  be  small,  or  the  abdominal  walls  be  very  tense. 
When  the  presenting  part  sinks  in  the  pelvis  there  is  likely  to  be 
some  increase  in  pressure.     (See  p.  3  14.) 

At  full  time  the  position  of  the  fundus  varies  according  to  the 
size  of  the  uterus.  It  is  frequently  found  at  the  level  of  the  lower 
margin  of  the  first  lumbar  vertebra.  In  the  erect  posture,  if  the 
abdominal  wall  be  lax,  it  reaches  a  somewhat  lower  level.  In  a 
primipara  it  is  probably,  on  the  average,  lower  than  in  a  multipara. 

The  distance  from  the  top  of  the  symphysis  to  the  fundus, 
measured  with  calipers,  ranges,  on  the  average,  from  9^  to  1 1  in. 
when  the  woman  is  in  the  dorsal  position.  In  the  erect  posture, 
if  the  long  axis  of  the  uterus  falls  in  line  with  that  of  the  pelvic 
inlet,  the  measurement  is  diminished.  In  a  primipara  described 
by  Braune  and  Zweifel  it  measured  ^\  in. 

The  method  of  measuring  the  elevation  of  the  uterus  in  refer- 
ence to  the  umbilicus  should  be  abandoned  on  account  of  the 
variability  of  the  latter  point.  For  clinical  purposes  it  is  best  to 
measure  the  distance  above  the  symphysis  ;  and  it  should  be 
remembered  that  the  outhne  of  the  uterus  can  be  accurately 
determined  only  during  a  period  of  hardening. 

Relation  of  the  Placenta. — The  placenta  is  most  frequently 
situated  entirely  in  the  upper  uterine  segment,  occasionally  partly 
in  the  upper  and  partly  in  the  lower  segments,  rarely  entireh'  in 
the  lower.  From  a  study  of  1000  cases  Caruso  states  that  it  is 
most  frequently  attached  to  the  anterior  wall,  occasionally  to  the 
posterior  wall,  seldom  to  the  right  side,  very  rarely  to  the  left 
side.  A  complete  fundal  insertion  is  also  ver}^  infrequent.  Its 
most  frequent  site  is  probably  the  right  upper  portion  of  the 
anterior  uterine  wall.  Bayer  and  Leopold  state  that  when  the 
placenta  is  situated  anteriorly  the  Fallopian  tubes  are  parallel  to 
the  long  axis  of  the  uterus  ;  when  it  is  attached  to  the  posterior 
wall  they  converge  anteriorly.  Palm,  in  describing  the  relationship 
between  the  placental  site  and  the  uterine  attachment  of  the  tubes 
and  round  ligaments,  states  : 


CHANGES  IN   THE   MATERNAL    SYSTEM.  lO/ 

1.  When  the  placenta  is  on  the  lower  part  of  the  posterior 
wall  the  uterus  is  symmetrical,  the  tubes  and  round  lic^aments 
being  attached  high,  somewhat  near  one  another,  and  at  the  same 
level. 

2.  When  the  placenta  is  on  the  lower  part  of  the  anterior  wall 
the  uterus  is  symmetrical,  but  the  tubes  and  round  ligaments  are 
attached  wide  apart  and  laterally. 

3.  When  it  is  posterior  and  high  the  uterus  is  symmetrical  and 
rounded,  the  tubes  and  round  ligaments  being  attached  lower  and 
nearer  one  another  on  the  anterior  wall. 

4.  When  it  is  anterior  and  high  the  uterus  is  symmetrical  and 
rounded,  the  tubes  and  ligaments  being  widely  separated  and 
attached  laterally. 

5.  When  it  is  situated  on  one  side,  near  the  fundus,  the  uterus 
is  asymmetrical,  one  corner  being  more  prominent  and  higher, 
the  attachments  of  the  tubes  and  round  ligaments  being  wide 
apart  at  the  sides  and  high. 

That  part  of  the  wall  to  which  the  placenta  is  attached  is 
usually  thinner  than  the  neighboring  portion.  The  placental  area 
varies  in  different  cases.  On  the  average  it  may  be  said  to  meas- 
ure about  one-fifth  of  the  total  inner  surface  of  the  uterus  at  full 
time. 

Intra=uterine  Pressure. — Milne  Murray  has  pointed  out  that 
there  is  a  positive  intra-uterine  pressure  during  pregnancy,  and 
that  it  is  greater  than  the  extra-uterine  pressure,  though  the 
difference  may  be  very  small.  It  is  impossible,  therefore,  that  the 
uterine  wall  can  in  normal  cases  be  flaccid.  If  flaccidity  is  ever 
found  in  a  post-mortem  specimen,  it  is  caused  by  some  change, 
such  as  the  escape  of  some  fluid  from  the  uterus. 

Circulatory  System. — Blood — The  total  quantity  of  blood 
in  the  body  is  increased,  accompanying  the  requirements  of  the 
increased  vascular  area  in  the  uterus.  It  is  relatively  more  watery 
than  in  the  non-pregnant  state.  There  is  less  serum-albumin, 
more  extractive  matter  and  fibrin.  The  increase  in  fibrin  elements 
is  especially  formed  during  the  last  three  or  four  months,  and  is 
due,  according  to  Nasse,  to  the  breaking  up  of  leukocytes,  which 
are  relatively  and  actually  greater  than  before  pregnancy.  Will- 
cocks  has  shown  that  the  red  corpuscles  are  somewhat  multiplied, 
but  are  relatively  less  abundant  than  in  the  non-pregnant  state. 
There  is,  therefore,  a  relative  diminution  of  hemoglobin,  although 
each  red  corpuscle  has  its  normal  amount  or  slightly  more  than 
normal. 

Ascoli  and  Edra  state  that  no  hyperleukocytosis  appears  in 
the  blood  of  the  pregnant  woman  until  just  before  the  expulsion 
of  the  child.  Hibbard  and  V/hite,  from  observations  made  in  the 
Boston  Lying-in  Hospital,  state  that  leukocytosis  is  found  in  more 
than  75  per  cent,  of  women  in  labor,  being  best  marked  and  more 


I08  ANATOMY  AND   PHYSIOLOGY  OF  PREGNANCY. 

frequent  in  primiparse ;  the  highest  counts  are  found  the  more 
advanced  the  labor ;  the  leukocytosis  is  due  to  an  increase  in  the 
polynuclear  cells.  Elder  and  Hutchinson,  in  ii  cases  at  term, 
found  an  average  of  14,522,  the  counts  varying  from  8000  to 
25,000.  Cabot  states  that  most  primiparae  show  a  moderate  increase 
of  all  varieties  of  leukocytes  during  pregnancy,  the  average  count 
being  13,000.  In  the  last  weeks  there  is  a  rise,  the  count  varying 
from  16,000  to  18,000.  He  found  an  increase  in  about  50  per 
cent,  of  multipara;.  He  thinks  that  all  varieties  of  the  leukocytes 
are  multiplied.  Henderson  found  an  increase  in  all  cases,  the 
lowest  counts  being  in  multiparae,  though  in  them  the  number 
never  fell  below  10,600.  In  38  cases  at  the  time  of  labor  he 
found  the  average  to  be  21,365  ;  the  lowest  count  being  10,600, 
the  highest  36,600,  He  found  that  the  leukocytosis  was  smaller 
with  a  male  in  iitcro  than  with  a  female.  In  weak  and  ill- 
nourished  women  the  leukocytes  are  much  diminished.  Pray 
regards  the  leukocytosis  as  partly  due  to  the  increased  action  of 
pelvic  lymph  glands,  and  partly  to  toxemia  due  to  the  increased 
metabolism. 

Heart. — According  to  Blot  the  weight  of  the  heart  increases 
one-fifth  in  pregnancy;  Lohlein  states  that  it  is  not  quite  as  much. 
This  is  due  to  muscular  hypertrophy  accompan}ing  increased 
work,  which  mainly  affects  the  left  half,  especially  the  left  ventri- 
cle ;  its  wall  thickens  about  25  per  cent.  There  is  also  slight 
hypertrophy  of  the  right  half,  for,  as  Charpentier  has  pointed  out, 
there  is  greater  tension  in  the  pulmonary  circulation,  and  this 
necessitates  more  work  on  the  part  of  that  side.  There  is,  in 
addition,  some  dilatation  of  both  sides  of  the  heart.  The  hyper- 
trophy remains  for  a  considerable  time  during  the  lactation  period, 
but  gradually  diminishes.  There  is  little,  if  any,  permanent  en- 
largement, and  it  is  very  doubtful  if  healthy  multiparae  have,  on 
the  average,  larger  hearts  than  nulliparae.  Murmurs  often  develop 
in  the  cardiac  area  in  advanced  gestation  ;  they  usually  disappear 
within  the  first  two  or  three  weeks  of  the  puerperium.  Lohlein 
found  them  in  68  per  cent,  of  cases  ;  Fritsch  in  78  per  cent.  They 
are  usually  soft  or  blowing  systolic  murmurs  heard  at  the  base 
or  apex. 

Stengel  and  Stanton  state  that  the  outward  displacement  of 
the  apex  in  advanced  pregnancy  is  due  to  upward  displacement 
of  the  diaphragm  from  pressure.  They  state  that  the  murmurs 
are  due  to  overaction  of  the  right  heart  and  to  distention  of  the 
conus  arteriosus. 

The  pulse  rate  is  not  usually  altered.  It  is  stated  by  some 
that  it  is  increased ;  by  others  that  it  is  diminished.  Jarissenne 
states  that  in  pregnancy  the  pulse  rate  does  not  vary  from  the 
horizontal  to  the  erect  posture.  (This  was  pointed  out  by  Graves 
in  connection  with  cardiac  hypertrophy  generally). 


CHANGES  IN   THE   MATERNAL   SYSTEM.  IO9 

Duroziez  states  that  after  delivery  the  heart  remains  enlarged, 
save  when  the  woman  does  not  suckle  ;  in  the  latter  circumstance 
it  diminishes  in  size  rapidly. 

Digestion  and  Metabolism. — In  the  early  months  the 
appetite  is  often  capricious ;  nausea  and  vomiting  being  very 
common,  especially  during  the  second  and  third  months.  In  the 
late  months  digestion  is  usually  more  active  and  the  appetite 
keener ;  during  this  period  there  is  a  great  tendency  to  constipa- 
tion. 

The  woman  increases  in  weight  apart  from  the  growing  uterus 
and  ovum.  There  is  usually  a  gain  of  10  to  15  pounds  during 
pregnancy,  the  gain  being  most  marked  during  the  last  two 
months.  In  some  cases  the  increase  is  much  less  than  10  pounds  ; 
in  others  considerably  greater  than  15.  The  increment  exists 
mainly  as  adipose  tissue,  which  is  most  noticeable  in  connection 
with  the  mammae,  hips,  and  abdominal  wall.  It  is  also  found  in 
the  omentum  and  elsewhere.  This  accumulation  represents  mate- 
rial to  be  used  in  supplying  nourishment  to  the  future  child. 

Winckel  estimates  the  average  gain  in  weight  in  pregnancy, 
from  all  causes,  as  1770  gr. ;  of  this  1000  belong  to  the  ovum, 
150  to  the  increased  genital  organs,  620  to  the  rest  of  the  body. 

Skin. — The  activity  of  the  sweat  and  sebaceous  glands  is 
heightened.  The  hair  often  improves  in  quality,  and,  if  it  has 
been  previously  falling  out,  ceases  usually  to  do  so.  Pigmenta- 
tion develops  in  various  parts — /.  c,  middle  line  of  abdomen, 
areolae  of  mammae,  axillae,  external  genitals,  etc.  It  is  thought 
by  some  that  this  may  be  associated  with  a  temporary  enlarge- 
ment of  the  suprarenal  bodies.  The  discoloration  does  not 
entirely  disappear  after  delivery,  traces  of  it  being  found  in  differ- 
ent parts.  Wychgel,  working  with  Veit,  states  that  in  the  skin 
there  is  an  excess  of  free  iron,  and  Veit  believes  this  is  due  to  the 
dissolving  action  of  the  fetal  syncytium  on  the  maternal  blood, 
the  hemoglobin  being  set  free  from  the  red  corpuscles. 

Respiration. — In  advanced  gestation  respiration  becomes 
almost  entirely  thoracic.  There  is  no  diminution  in  the  size  of 
the  thoracic  cavity  even  though  the  diaphragm  is  somewhat 
elevated,  because  of  the  increased  basal  diameters.  Dohrn  shows 
that  this  is  more  marked  in  the  transverse  than  in  the  antero- 
posterior diameter.  The  amount  of  carbonic  acid  gas  expired  is 
considerably  greater  than  in  the  non-pregnant  state. 

Temperature. — It  is  believed  that  the  body  temperature  is 
slightly  elevated  in  pregnancy.  Winckel  states  that  on  the  aver- 
age the  increase  amounts  to  2°  or  3°  C.  Gruher  noted  it  in  96 
cases,  and  found  the  average  morning  temperature  to  be  37.46°  C, 
and  the  average  evening  temperature  37.36°  to  37.32°  C. 

I/OCOmotion. — As  the  abdomen  becomes  more  prominent 
tlie  woman  alters  the  position  of  her  body  in  order  to  adjust  the 


no  ANATOMY  AND  PHYSIOLOGY  OF  PREGNANCY. 

center  of  gravity.  If  she  is  tall  she  walks  with  the  shoulders 
thrown  well  back  ;  if  short  she  throws  back  the  whole  body. 

Urinary  System. — The  kidneys  probably  become  slightly 
enlarged  during  pregnancy.  The  urine  is  increased  in  quantity ; 
the  specific  gravity  is  lower,  being  about  1014  ;  the  urea  excreted 
is  normal.  These  changes  are  directly  associated  with  the  in- 
creased maternal  circulation  and  arterial  tension.  Sugar  is  found 
in  a  number  of  cases,  not  a  true  glycosuria,  but  a  lactosuria  due 
to  the  milk-sugar  in  the  blood,  derived  from  the  breasts.  This  is 
more  frequently  found  after  delivery.  Peptones  are  occasionally 
found,  being  thought  by  many  to  indicate  death  of  the  fetus, 
though  there  is  no  proof  whatever  of  this.  They  are  more  fre- 
quently found  after  labor,  where  they  are  probably  due  to  changes 
in  the  involuting  uterus.  R.  Costa  states  that  acetonuria  cannot 
be  regarded  as  a  sign  of  fetal  death.  He  has  found  it  in  normal 
pregnancy,  chiefly  near  full  term,  and  states  that  it  increases  during 
labor,  especially  if  prolonged ;  in  the  puerperium  it  diminishes, 
remaining,  however,  greater  than  in  gestation  for  at  least  six  days. 
Merletti  states  that  in  the  last  three  months  of  pregnancy  bile  is 
found  in  the  urine  in  double  and  treble  the  amount  found  in  the 
non-pregnant  state.  He  has  noted  also  an  increase  following 
death  of  the  fetus.  Wychgel  states  that  there  is  an  excess  of  free 
iron  in  the  urine  of  pregnant  women  as  compared  with  that  of  non- 
pregnant women,  and,  with  Veit,  thinks  that  it  may  be  due  to  the 
hemolytic  action  of  the  fetal  syncytium  on  the  maternal  red  blood 
corpuscles.  (The  appearance  of  albumin  will  be  considered  in 
the  section  dealing  with  the  Pathology  of  Pregnancy). 

Frequency  of  Micturition. — As  a  result  of  the  pressure  of 
the  uterus  on  the  bladder  during  the  first  three  months  of  preg- 
nancy, frequent  urination  is  often  noticed.  Many  variations  are 
found  as  regards  the  duration  of  this  disturbance.  Sometimes  it 
may  last  only  a  few  days  ;  generally  several  weeks.  Occasionally 
it  is  entirely  absent.  Usually  it  disappears  as  the  uterus  rises  into 
the  abdomen,  but  it  may  sometimes  persist.  This  symptom  is 
most  marked  in  women  who  have  suffered  from  prolapse  of  the 
pelvic  floor.  In  the  last  month  of  pregnancy  frequent  micturition 
is  again  often  noticed.  This  is  due  to  the  sinking  of  the  uterus 
that  takes  place  during  this  period. 

Reflex  and  Blectric  Bxcitability. — Tridondani  states 
that  in  pregnant  women  the  superficial  reflexes  are  diminished, 
with  the  exception  of  the  abdominal  one,  which  is  a  little  increased 
in  primiparae.  The  deep  and  tendon  reflexes  are  much  increased, 
especially  the  patellar.  The  pharyngeal  and  pupil  reflexes  are 
weakened,  the  latter  showing  a  condition  resembling  the  Argyll- 
Robertson  phenomenon.  He  also  states  that  the  electric  excita- 
bility is  diminished.  All  of  these  changes  are  more  marked  in 
primiparae    than    in    multiparse,    and    late    in    pregnancy    rather 


BACTERIOLOGY  OF   THE    VAGINA    IN  PREGNANCY.       Ill 

than  early.      There  is  a  return  to  normal  about  ten  days  after 
labor. 

Glandular  Changes. — The  thyroid  enlarges,  causing  in- 
creased fulness  of  the  neck.  This  hypertrophy,  no  doubt,  is 
related  to  the  altered  metabolism  that  characterizes  the  preg- 
nant state.  It  seems  to  be  well  established  that  the  internal 
secretion,  iodothyrin,  exercises  an  antitoxic  or  medicinal  effect 
upon  the  toxic  products  of  proteid  metaboUsm.  The  spleen, 
liver,  and  suprarenals  are  also  enlarged. 


CHAPTER   II. 

BACTERIOLOGY  OF  THE  VAGINA  IN  PREGNANCY. 

There  has  been  much  difference  of  opinion  as  to  the  normal 
condition  of  the  vagina  during  pregnancy,  but  the  causes  of  their 
differences  have  been  recently  fairly  well  elucidated,  and  at  the 
present  time  it  may  be  accepted  as  proved  that  the  genital  canal 
tends  to  be  maintained  in  a  state  of  asepticity  by  natural  means. 
Conner  first  definitely  stated  this  in  1887.  He  examined  31  women 
and  found  no  pathogenic  organisms  in  the  vagina,  but  only  various 
germs  which  would  not  grow  on  the  ordinary  culture  media.  He, 
therefore,  maintained  that  prophylactic  vaginal  douches  were  un- 
necessary, and  that  autoinfection  of  a  woman  could  not  occur. 
Doderlein,  in  the  same  year,  made  a  series  of  examinations  and 
announced  that  pathogenic  organisms  were  frequently  present, 
from  which  cultures  could  be  obtained,  and  he  opposed  Conner, 
urging  the  use  of  prophylactic  douches. 

Winter,  in  1886,  Staffeck,  Burgubum  and  Witte,  in  1890,  came 
to  conclusions  somewhat  similar  to  those  of  Doderlein.  Doder- 
lein, in  1892,  made  a  further  series  of  examinations  in  195  preg- 
nant women,  and  stated  that  he  found  two  distinct  types  of 
secretion.  One  of  these,  termed  normal,  was  a  white,  thickish, 
crumbly  material,  acid  in  reaction,  containing  epithelial  cells, 
occasional  yeast  cells,  and  many  thick  bacilli.  The  other  secre- 
tion, termed  abnormal,  was  more  fluid  and  pus-like,  less  acid  in 
reaction,  often  being  neutral  or  alkaline,  containing  many  leuko- 
cytes, epithelial  cells,  and  all  varieties  of  bacteria,  especially  cocci 
and  short  bacilli.  Cultures  from  the  normal  secretion  were  almost 
always  sterile.  Those  from  the  abnormal  secretion  showed  posi- 
tive results,  various  pathogenic  organisms  being  found,  streptococci 
in  10  per  cent,  of  cases.  He  obtained  the  normal  secretion  in  55.3 
per  cent,  of  his  cases,  and  the  abnormal  in  44.6  per  cent.  As  a 
result  of  his  work  he  modified  his  original  view,  stating  that  in 


112      BACTERIOLOGY  OF   THE    VAGINA    IN  PREGNANCY. 

those  women  with  the  abnormal  secretion  autoinfection  might 
occur,  and  that  in  them  prophylactic  douches  should  be  em- 
ployed. 

Whitridge  Williams,  in  1893,  examined  15  cases,  and  found 
Doderlein's  normal  secretion  in  5  and  the  abnormal  secretion  in 
10.  Cultures  of  pathogenic  organisms  were  obtained,  streptococci 
being  found  in  20  per  cent,  of  all  the  cases. 

Kronig,  in  1894,  studied  100  cases,  examining  the  vaginal 
secretion  of  pregnant  women  in  all  conditions,  normal  and 
pathologic,  and  did  not  find  septic  organisms,  nor  any  which 
would  grow  aerobically  on  ordinary  media  at  body  temperature, 
save  in  a  i&\N  instances  gonococci  and  yeast  organisms.  He, 
therefore,  expressed  the  view  that  the  vagina  of  e\'ery  pregnant 
woman  not  recently  contaminated  by  digital  or  instrumental 
examination  or  coitus  is  aseptic.  In  221  cases  he  found  Doder- 
lein's normal  secretion  in  117;  the  abnormal  in  104.  Of  the 
former,  30.8  per  cent,  had  an  abnormal  puerperal  history,  and 
29.8  per  cent,  of  the  latter. 

In  1894  Doderlein  challenged  the  soundness  of  Kronig's 
views.  Kronig  thereupon  carried  out  a  series  of  interesting 
experiments  on  pregnant  women,  to  determine  the  bactericidal 
action  of  the  vaginal  secretion.  Cultures  of  the  bacillus  pyo- 
cyaneus  were  introduced  into  the  vagina.  They  were  destroyed 
in  all  cases  after  a  number  of  hours,  varying  in  different  instances, 
the  average  being  20  hours.  They  were  destroyed  most  rapidly 
where  the  vaginal  secretion  contained  cultures  of  Doderlein's  long 
vaginal  non-pathogenic  bacilli ;  less  rapidly  in  those  containing 
short  rods  and  cocci.  All  pathogenic  staphylococci  introduced 
were  destroj-ed  within  twenty  hours ;  streptococci  within  six 
hours.  He  concluded  that  the  vagina  becomes  aseptic,  at  most, 
within  two  or  three  da}-s  after  foreign  material  is  introduced  into 
it.  He  also  stated  that  antiseptic  douches  weakened  or  destroyed 
the  natural  antiseptic  action  of  the  secretion. 

Menge,  in  1894,  confirmed  Kronig's  views,  showing  that  the 
natural  antiseptic  action  exists  in  the  non-pregnant  state,  though 
not  so  strongly  as  in  pregnancy.  In  1897  Kronig,  having  investi- 
gated an  additional  large  number  of  cases,  emphasized  his  previous 
statements.  He  maintained  that  the  work  of  those  who  had 
found  pathogenic  organisms  in  the  vagina  had  been  faulty  ;  that 
these  organisms  had  been  introduced  from  the  vulva  as  the  result 
of  careless  technic.  His  own  method  was  so  devised  as  to  make 
contamination  impossible. 

Whitridge  Williams  in  1898  made  a  new  series  of  observa- 
tions based  upon  Kronig's  method  of  examination,  and  as  a  result 
corroborated  the  views  expressed  by  Kronig  and  Menge.  revers- 
ing his  earlier  opinions,  which  had  been  based  upon  faulty  tech- 
nic.    He  showed  that  the  ordinary  methods  employed  in  obtaining 


DIAGNOSIS   OF   UTERINE   PREGNANCY.  113 

the  vaginal  secretion  are  likely  to  introduce  organisms  from  the 
vulva,  which  is  rich  in  pathogenic  and  other  microbes.  His  con- 
clusion was  that  there  is  nothing  to  indicate  that  the  vaginal 
secretion,  whether  of  the  normal  or  abnormal  nature  described 
by  Doderlein,  contains  pyogenic  cocci  which  can  cause  puerperal 
infection.  As  regards  saprophytes,  our  knowledge  is  compara- 
tively scanty.  Conner  states  that  there  are  none  in  the  vaginal 
secretion,  either  aerobic  or  anaerobic.  It  is  not  impossible^'that 
some  of  the  non-pathogenic  germs  which  ordinarily  exist  in  the 
vagma  may  occasionally  act  as  saprophytes,  but  there  is  no  proof 
of  this  as  yet. 

In  view  of  the  above-mentioned  results,  it  is  evident  that  in 
the  great  majorit)-  of  cases  prophylactic  douching  in  pregnancy  is 
unnecessary.  Neither  is  it  necessary  after  labor  if  the  woman  be 
not  exposed  to  contamination  by  those  who  attend  her  during 
parturition. 


CHAPTER    III. 

DIAGNOSIS  OF  UTERINE  PREGNANCY. 

The  diagnosis  of  pregnancy  is  often  easy,  but  in  a  considerable 
proportion  of  cases  it  is  such  a  difficult  matter  that  the  most 
experienced  physician  may  easily  fall  into  error.  The  most  care- 
ful consideration  should  be  given  to  the  two-fold  foundation  upon 
which  the  diagnosis  is  established— viz.,  the  data  furnished  by  the 
woman  regarding  herself,  and  those  obtained  through  the  phvsi- 
cian's  physical  examination.  The  most  important  of  these  are'the 
latter,  and  in  cases  of  difficulty  should  be  held  in  far  more  serious 
consideration  than  the  former.  Women's  histories  are  often  mis- 
leading, from  stupidity,  nervousness,  inaccuracy  of  observation  or 
from  a  wilful  desire  to  deceive ;  too  great  caution  cannot  be  exer- 
cised m  interpreting  them.  Care  must  be  taken  also  not  to  lay 
too  much  stress  upon  one  or  other  symptom  or  sign  There  are 
many  variations  in  the  development  of  the  phenomena  of  preo-- 
nancy,  and  it  is  important  that  the  deviations  from  the  normal  be 
continually  remembered. 

SIGNS  AND  SYMPTOMS. 

Altered  Menstrual  Function.— In  the  great  majority  of 
cases  menstruation  ceases  after  conception  and  does  not  appear 
during  the  course  of  pregnancy.  The  non-appearance  of  men- 
struation in  a  healthy  adult  woman  whose  periods  have  previously 
been    regular   must  always   justify  the  suspicion   of   pregnancy 


114  DIAGNOSIS   OF   UTERINE   PREGNANCY. 

particularly  if  she  is  known  to  have  subjected  herself  to  sexual 
intercourse.  In  some  cases  after  conception  a  discharge  of  blood 
may  take  place  from  the  uterus  at  times  corresponding  to  men- 
struation, even  when  the  relationships  of  ovum  and  deciduse  are 
normal.  Most  frequently  this  occurs  only  once,  probably  in  the 
cases  in  which  conception  took  place  immediately  before  an  ex- 
pected period.  The  discharge  is  usually  derived  from  the  decidua 
vera  (sometimes  from  the  reflexa),  and  escapes  through  the  cervix 
from  the  space  between  the  vera  and  reflexa.  Rarely  there  is  a 
monthly  discharge  on  more  than  one  occasion.  The  duration 
and  quantity  of  blood  are  usually  much  less  than  normal. 
Records  have  been  made  of  a  few  cases  in  which  periodic  bleed- 
ings have  occurred  throughout  pregnancy. 

When  pregnancy  takes  place  in  one-half  of  a  bicornute  or 
septate  uterus,  such  escapes  of  blood  from  the  other  half  have 
been  frequently  noted.  In  many  instances  in  which  discharges 
of  blood  are  noted  some  pathologic  condition  exists — i.  c,  uterine 
polypi,  inflammation,  malignant  disease,  placenta  praevia,  etc.  In 
cases  of  gestation  outside  the  uterine  cavity,  discharges  of  blood 
from  the  uterus,  occurring  in  great  variations  as  regards  frequency, 
duration  and  quantity,  are  common.  It  is,  therefore,  evident  that 
errors  in  diagnosis  may  arise  if  it  be  not  remembered  that  preg- 
nancy may  be  accompanied  occasionally  by  discharges  of  blood 
from  the  uterus.  As  a  diagnostic  sign  the  menstrual  phenomena 
fail,  also,  when  pregnancy  occurs  during  a  period  of  amenorrhea, 
due  to  normal  or  pathologic  conditions.  This  must  be  remem- 
bered in  connection  with  its  occurrence  in  early  life,  before  men- 
struation has  ever  been  established ;  in  the  skipping-time  often 
associated  with  the  establishment  of  puberty;  during  lactation 
and  the  irregular  intervals  of  the  menopause.  In  some  cases  the 
menstrual  type  is  veiy  irregular,  though  the  woman  be  healthy, 
leading  to  a  simulation  of  a  missed  menstruation.  Often  the 
amenorrhea  is  due  to  some  local  or  general  disturbance  of  the 
system. 

Nausea  and  Votnitingf. — In  a  large  number  of  cases  nausea 
and  vomiting  occur  in  the  first  half  of  pregnancy,  apart  from  any 
recognizable  pathologic  change.  They  are  generally  regarded  as 
being  reflexly  caused  by  the  growing  uterus,  though  at  the  pres- 
ent time  they  are  believed  by  many  to  be  manifestations  of  preg- 
nancy toxemia.  The  disturbances  begin  usually  during  the  second 
month  and  rarely  last  beyond  the  end  of  the  fourth  month.  They 
may  sometimes  develop  during  the  first  month,  may  extend  beyond 
the  twelfth  week,  occasionally  lasting  until  the  end  of  pregnancy. 
In  rare  cases  they  may  develop  during  the  last  weeks. 

Many  variations  are  found  in  the  manifestations  of  these  dis- 
orders. Often  the  woman  feels  nauseated  immediately  on  rising 
from  bed  in  the  morning.     This  is  frequently  accompanied  by  the 


ALTERED   NERVOUS  STATE— QUICKENING.  II5 

vomiting  of  a  small  or  large  quantity  of  acid,  glairy  mucus.  In 
many  cases  the  woman  has  no  more  trouble  throughout  the 
day.  In  some  cases  vomiting  occurs  immediately  or  one  or  two 
hours  after  the  first  food  taken.  Some  women  are  troubled 
several  times  a  day.  In  some  vomiting  may  be  brought  on  by 
any  exertion,  excitement,  or  agitation.  Rarely  the  disturbance 
occurs  only  at  night,  when  the  woman  goes  to  bed.  Generally 
the  attack  is  followed  by  a  feeling  of  complete  relief,  but  in  some 
cases  by  distress ;  its  duration  varies  considerably.  Salivation 
often  accompanies  the  nausea,  being  in  some  cases  very  marked. 
Sometimes  ptyalism  is  more  troublesome  than  the  nausea.  Rarely 
vomiting  is  followed  by  diarrhea.  In  most  cases  women  do  not 
suffer  as  regards  their  general  health,  but  occasionally  they  get 
worn,  thin,  and  anemic.  (Pernicious  vomiting  is  described  on 
page  301.)  The  importance  of  nausea  and  vomiting  alone  as  an 
indication  of  pregnancy  is  not  great,  since  many  diseased  condi- 
tions produce  them.  Their  occurrence  as  reflex  disturbances  in 
various  pelvic  disorders  must  be  remembered. 

Altered  Nervous  State. — In  some  cases  no  change  can  be 
noted  in  the  nervous  equilibrium.  Often  there  is  increased  emo- 
tional susceptibility,  and  exhibitions  of  peevishness,  fretfulness, 
irritability,  and  unreasonableness.  Sometimes  there  is  more  or 
less  depression  of  spirits.  Occasionally  there  is  increased  buoy- 
ancy and  mental  activity.  Sometimes  greater  sluggishness  of 
mind  and  enfeeblement  of  memory  are  noted.  There  may  be  a 
change  in  the  woman's  esthetic  and  moral  senses.  She  may 
become  careless,  slovenly,  dirty ;  she  may  deviate  into  dishonesty, 
untruthfulness,  and  sometimes  lasciviousness.  Her  appetite  occa- 
sionally becomes  strangely  altered.  She  may  try  to  eat  sub- 
stances which  are  not  used  for  food — /.  e.,  plaster,  paper,  etc.,  or 
may  desire  abnormal  quantities  of  such  articles  as  salt,  pepper, 
vinegar,  or  may  crave  for  foods  which  are  out  of  season.  Some- 
times the  perversion  of  appetite  is  of  a  very  distressing  nature. 

Quickening. — This  term  is  applied  to  the  woman's  apprecia- 
tion of  the  fetal  movements.  Generally  the  sensation  is  expe- 
rienced between  the  sixteenth  and  eighteenth  weeks,  rarely  earlier, 
occasionally  at  a  later  date.  Ordinarily  the  earliest  movements 
are  compared  to  a  feeble  fluttering.  Sometimes  a  woman  never 
feels  movements  throughout  pregnancy  or  only  toward  the  end. 
The  movements  may  often  be  increased  by  long  fasting,  by  palpa- 
tion of  the  abdomen,  or  by  application  of  cold  to  it.  Normally 
women  feel  quickening  at  about  the  same  time  in  successive  preg- 
nancies. Too  much  prominence  must  not  be  given  to  this  symp- 
tom in  diagnosing  pregnancy.  A  married  woman  who  has  had 
children  is  not  often  deceived,  but  others  may  be.  Movements 
of  gas  in  the  bowel,  changes  in  the  position  of  tumors,  contrac- 
tions in  the  muscles  of  the  abdominal  wall,  may  simulate  fetal 


Il6  DIAGNOSIS   OF   UTERINE   PREGNANCY. 

movements.  Occasionally  pregnant  women  describe  a  sensation 
in  the  early  weeks  that  is  entirely  imaginary.  So,  also,  non- 
pregnant women  who  have  exposed  themselves  to  the  risk  of  im- 
pregnation may  imagine  that  they  feel  movements  of  a  fetus. 

Mammary  Changes. — Enlargement  of  the  breasts  usually 
takes  place,  being  first  appreciable  toward  the  end  of  the  second 
month.  This  is  due  to  hypertrophy  and  hyperplasy  of  the  gland 
tissues,  recognizable  by  an  increased  firmness  and  by  an  uneven, 
knotty  character.  The  change  is  generally  first  distinguished  at 
the  periphery  of  the  breast.  In  some  cases  the  enlargement  is 
very  marked ;  in  others  scarcely  any  increase  may  be  made  out 
during  the  whole  of  pregnancy.  Between  these  extremes  many 
variations  are  found. 

In  many  women  mammary  increase  is  partly  due  to  deposit 
of  fat  around  the  glandular  lobules  and  under  the  skin,  this  de- 
velopment being  most  marked  during  the  last  three  months.  The 
greater  the  subcutaneous  deposit  the  less  distinctly  can  the  lobules 
of  breast  tissue  be  palpated.  As  a  result  of  the  stretching  of  the 
skin  caused  by  breast  hypertrophy  the  cutis  Trr^  becomes  thinned 
in  different  parts,  giving  rise  to  the  surface  appearance  known  as 
"  striae."  These  are  similar  to  those  found  in  the  abdomen.  They 
may  be  faintly  or  strongly  marked,  or  in  some  cases  entirely 
wanting.  They  occur  around  the  edge  or  on  the  breast  surface. 
Old  striae  are  white ;  recent  ones  vary  from  a  pale  pink  to  a  deep 
rosy  hue.  In  some  women  the  whole  breast  feels  full  and  firm ; 
in  others  there  is  more  or  less  relaxation.  Palpation  may  cause 
some  women  to  complain  of  pain  or  soreness  in  the  breasts. 
Apart  from  palpation,  many  describe  a  feeling  of  fulness,  tingling, 
or  sensitiveness,  especially  in  the  early  months. 

Veins. — The  veins  are  larger,  and  in  most  cases  are  seen  as 
blue  lines  under  the  skin,  sometimes  forming  distinct  elevations. 

Areola. — The  areola  becomes  darker  in  color,  usually  in  the 
second  month,  the  most  marked  change  occurring  in  brunets,  in 
Avhom  it  is  dark  brown.  The  lighter  the  woman's  complexion 
the  less  pigmented  is  the  areola.  In  some  blonds  it  may  appear 
pale  rose-colored,  scarcely  any  change  from  the  non-pregnant 
state  being  appreciable.  Elevation  of  the  areola  is  noticeable 
in  some  cases,  giving  rise  occasionally  to  the  appearance  of 
a  miniature  breast.  It  often  appears  wrinkled,  due  to  contrac- 
tion of  bands  of  subcutaneous  muscle.  Irritation  of  the  sur- 
face, or  mental  influences,  bring  about  an  areolar  puckering, 
which  is  usually  accompanied  by  some  forward  projection  of 
the  nipple.  Scattered  over  the  areola  are  small  nodules  known 
as  Montgomery's  tubercles,  varying  in  number  from  two  or 
three  to  twenty.  They  are  enlarged  sebaceous  follicles.  Their 
secretion  moistens  the  skin  and  may  sometimes  be  very  abun- 
dant.    Occasionally  these  prominences  may  be  entirely  wanting. 


PLATE     7. 


Montgomery's  follicles  (F),  largely  developed.  Erectility  of  nipple  and  primary  areola. 


Veins  coursing  over  the  breast  and  primary  areola, 
with  irregular  pigmentation  (in  a  blonde). 


Milk,  with  faint  secondary  areola  (in  a  brunette). 


Secondary  areola  of  usual  size  (in  a  brunette).  Secondary  areola,  prominently  marked  (S),  with 

wide  primary  (P)  areola  (in  a  brunette). 

Mammary  sif^ns  of  jiretrnancy  in  thcii'  order  (two-thirds  life  size). 


ABDOMINAL    SIGNS.  I  1/ 

External  to  the  uniformly  darkened  areola  above  described,  known 
as  the  "  primary  areola,"  there  appears  about  mid-term  a  patchy 
pigmentation  known  as  the  "  secondary  areola."  It  consists  of 
small,  round,  pale  spots  surrounded  by  darkened  skin;  in  the 
center  of  each  spot  is  the  opening  of  a  sebaceous  gland.  This 
appearance  is  usually  found  in  brunets,  rarely  in  blonds  ;  it  may 
extend  over  a  small  or  large  area. 

During  the  third  month  and  thereafter  colostrum  may  be 
squeezed  from  the  nipple,  and  appears  as  a  clear  pale  or  yellow 
fluid  in  the  early  months ;  later  it  usually  becomes  opaque.  In 
some  instances  it  may  be  found  earlier  than  the  third  month  ; 
in  others  only  toward  the  end  of  pregnancy ;  rarely  it  cannot 
be  obtained  at  all.  In  cases  where  it  is  abundant  it  may  ooze 
from  the  nipples  and  then  dry  and  form  a  scale.  The  nipples 
usually  become  larger  and  more  prominent  in  pregnancy,  but 
sometimes  little  or  no  change  is  visible.  In  cases  where  there 
is  depression  of  a  nipple  the  condition  may  be  more  marked  as 
the  surrounding  tissue  increases  in  size. 

Value  of  the  Mammary  Signs  in  the  Diagnosis  of  Preg= 
nancy. — In  a  woman  who  has  never  before  conceived  the  various 
signs  above  described  are,  alone,  suggestive  of  pregnancy.  In  a 
multipara,  in  whose  breast  there  are  usually  striae  and  permanent 
darkening  of  the  areola,  they  are  much  less  suggestive.  There  is 
a  greater  probability  of  pregnancy  if  there  be  a  history  of  cessation 
of  menstruation  and  morning  sickness.  However,  in  some  instances 
such  a  combination  may  occur  apart  from  gestation.  Any  or  all  of 
these  breast  changes  may  occur  reflexly  from  various  pelvic  and 
abdominal  disturbances — /.  e.,  tumors,  displacements,  chronic  in- 
flammation ;  or  they  may  occur  in  connection  with  a  disturbed 
imagination  or  other  neuroses.  In  the  various  forms  of  spurious 
pregnancy  they  are  usually  present.  It  is  very  rare  that  in  these 
states  the  mammary  signs  are  so  pronounced  as  in  a  typical  preg- 
nancy. In  ectopic  gestation  they  are  usually  less  marked  than  in 
uterine  cases.  If  desirous  of  examining  the  breasts  of  an  unmar- 
ried girl  in  whom  pregnancy  is  suspected,  it  is  well  to  make  the 
pretence  of  listening  to  the  heart  and  lungs  in  order  to  distract 
her  attention. 

Abdominal  Signs. — Pigmentation — In  the  fourth  month 
a  pigmented  line  begins  to  be  noticed,  extending  mesially  from 
the  pubes  toward  the  ensiform  cartilage.  In  blonds  it  is  faintly 
marked ;  in  brunets  pronounced.  Ordinarily  its  width  varies  from 
I"  to  i  inch  ;  sometimes  it  is  greater  than  this.  In  some  cases 
it  is  much  more  distinct  below  than  above  the  navel.  In  dark 
women  pigmentation  may  also  be  very  evident  in  the  stride  and 
in  the  region  of  the  mons  veneris. 

Striae  develop  during  the  second  half  of  pregnancy,  especially 
in  the  last  two  months.    They  are  termed  "  striae  gravidarum  "  or 


Il8  .DIAGNOSIS   OF  UTERINE  PREGNANCY. 

"  lineae  albicantes."  They  are  stretched  and  thinned  portions  of 
the  connective  tissue  of  the  cutis  vera.  Recent  ones  are  pale 
pink,  rosy,  or  purplish ;  old  stria  are  white  and  scar-like.  They 
are  irregular  in  shape  and  size  and  vary  greatly  in  number  in 
different  cases.  They  are  most  abundant  in  the  lower  half  of  the 
abdomen  and  around  the  navel,  and  may  often  be  found  on  the 
thighs  and  buttocks.  In  the  region  of  the  umbilicus  the  long 
axis  of  the  striae  are  often  arranged  somewhat  concentricall}'. 
Occasionally  no  striae  are  produced  at  all  by  the  distention  of 
pregnancy.  But  this  is  found  only  in  about  5  or  6  per  cent,  of 
cases.  Sometimes  careful  search  may  reveal  faint  traces  of  striae 
where  they  are  thought  not  to  exist.  It  must  be  remembered 
that  these  striae  are  not  characteristic  of  pregnancy,  but  may  be 
produced  by  skin-stretching  due  to  other  causes — /.  e.,  adiposity, 
ascites,  abdominal  tumors. 

Separation  of  the  recti,  due  to  stretching  of  the  linea  alba,  is 
very  frequently  found  in  slight  degrees  in  primiparae  in  advanced 
pregnancy.  In  multiparae  it  is  usually  more  marked.  It  may  be 
found  only  near  the  navel  or  above  and  below  it.  In  thin  women 
it  may  be  sometimes  recognized  as  a  depression  of  the  skin  between 
the  edges  of  the  recti.  General!}-  it  can  best  be  made  out  by  placing 
the  hand  on  the  abdomen  as  the  woman  brings  the  recti  into 
action.  The  uterus  is  very  distinctly  palpated  through  the  af- 
fected area.  In  extreme  cases  the  recti  may  be  separated  several 
inches,  so  that  in  the  erect  position  the  anterior  wall  of  the  uterus 
bulges  between  them  when  the  woman  stands  erect.  The  umbili- 
cus tends  to  become  everted  as  the  abdomen  increases,  so  that  by 
the  sixth  month  its  deepest  portion  is  about  level  w^ith  the  skin 
surface ;  thereafter  it  usually  forms  a  local  convexity.  In  dark 
women  it  is  surrounded  by  a  ring  of  pigment,  continuous  with  the 
linea  nigra. 

The  size  and  shape  of  the  abdomen  var}^  at  different  periods 
in  different  conditions  of  the  woman  and  of  the  uterine  contents. 
During  the  first  three  months  of  pregnancy,  while  the  uterus  is 
within  the  pelvis,  it  is  held  by  some  authorities  that  the  lower  ab- 
dominal region  is  slightly  diminished  in  its  anteroposterior  diameter 
owing  to  some  sinking  of  the  pelvic  floor.  This  statement  is  of  no 
clinical  importance,  for  the  eye  cannot  distinguish  any  such  change. 
Bulging  of  the  lower  abdominal  wall  may  first  be  noticed  in  the 
fourth  month  ;  thereafter  it  progressively  increases.  In  general 
it  may  be  said  that  the  bulging  is  mesial  and  symmetrical.  Many 
variations  from  this  condition  are  to  be  noted.  Asymmetry  is 
most  frequently  observed  in  multiparas.  In  primiparae  whose 
abdominal  walls  are  firm  and  unstretched  the  abdominal  enlarge- 
ment is  usually  uniform  ;  this  is  most  likely  to  be  the  case  when 
the  woman  is  fat.  Asymmetry  is  most  often  due  to  projections 
outward  of  fetal  parts,  but  it  may  be  due  to  deviations  of  the 


A  BD  OMINA  L   SIGNS. 


119 


Uterus  as  a  whole ;  sometimes  it  is  due  to  pathologic  condi- 
tions— /.  c,  tumors  and  other  swellings.  The  shape  may  change 
in  a  short  time  in  some  cases  owing  to  fetal  movements,  these 
being  often  visible  on  inspection.  Ordinarily  it  is  stated  that  at 
the  sixth  month  the  fundus  reaches  the  umbilicus,  and  near  the 
end  of  the  eighth,  the  ensiform.  This  is  inaccurate.  The  navel 
varies  in  its  position  and  should  not  be  taken  as  a  landmark.  The 
ensiform  is  often  never  reached  at  all  by  the  fundus.  The  varia- 
tions in  the  size  of  the  abdomen  in  different  cases  are  mainly 
related  to  the  size  of  the  fetus  and  quantity  of  liquor  amnii,  and 


Fig.  67. — Locating  cephalic  prominence  by  palpation  with  both  hands.    The  hand  sinks 
deeper  in  the  pelvis  at  the  side  on  which  the  occiput  hes  (Leopold). 


to  the  laxity  of  the  abdominal  walls.  Ceteris  paribus,  \h&  swelling 
is  less  prominent  in  primiparae  than  in  multiparae.  In  women  with 
contracted  pelvic  brim  there  is  more  prominence  of  the  abdomen, 
since  the  uterus  and  fetus  cannot  sink  within  the  pelvis.  Its  size 
is  also  increased  when  there  are  pathologic  swellings  in  the  abdo- 
men. 

It  is  often  noticed  that  during  the  last  month  of  pregnancy 
the  fundus  sinks  somewhat.  In  primiparae  this  is  generally  due 
to  the  sinking  of  the  uterus  vertically  as  a  whole  (clinically  this 
is  described  as  a  sinking  of  the  fetal  head  within  the  true  pelvis). 


120 


DIAGNOSIS    OF   UTERINE   PREGNANCY. 


In  multiparee  the  lower  position  of  the  fundus  is  mainly  due  to 
descent  of  the  latter  forward  and  downward  as  a  result  of  increased 
weakening  of  the  anterior  abdominal  wall ;  the  distance  varies 
greatly  in  different  cases.  The  reason  of  the  sinking  of  the 
uterus  as  a  whole  in  primipara^  is  the  strength  and  resistance 
of  the  abdominal  wall ;  as  the  uterus  increases  it  is  forced  in  the 
direction  of  least  resistance — /.  c,  downward.  In  multiparae  it  is 
rare  to  find  the  fetal  head  within  the  pelvis  at  full  term,  whereas 
in  primiparae  it  is  the  rule.     The  head  may  be  prevented  from 


Fig.  68. — Examination  of  upper  fetal  pole,  showing  relation  of  examining  hands  to 
fetal  parts  (Leopold). 

entering  the  pelvis  in  primiparai  by  various  factors — /.  c,  con- 
tracted pelvis,  large  head,  tumors,  and  by  the  attachment  of  the 
placenta  to  the  lower  uterine  segment.  The  uterus  may  first  be 
palpated  through  the  abdomen  in  pregnancy  in  the  fourth  month, 
when  the  fundus  and  part  of  the  anterior  wall  can  be  felt.  There- 
after an  increasing  area  comes  into  relation  with  the  abdominal 
wall. 

The  consistence  of  the  uterine  tumor  varies  from  time  to 
time.  In  its  softened  and  relaxed  condition  it  resembles  a  bag 
incompletely  filled  with  water,  its  outline  being  difficult  to  define. 
In  this  state  the  fingers  may  usually  indent  the  wall  so  that  the 
fetus  may  be  palpated.    That  part  of  the  uterus  to  which  the  pla- 


ABDOMINAL    SIGNS.  121 

centa  is  attached  is  less  elastic  and  more  boggy  than  the  rest  of 
the  wall.  In  the  hardened  condition  of  the  uterus  the  outline 
may  easily  be  distinguished  and  the  fingers  usually  cannot  feel 
the  fetal  parts  ;  this  change  is  due  to  contractions  of  the  uterine 
musculature  not  sufficient  to  cause  pain.  They  occur  at  intervals 
varying  from  five  to  ten  minutes  and  last  from  one-half  to  four  or 
five  minutes.  They  are  involuntary  and  independent  of  external 
stimuli,  though  they  may  be  induced  by  palpation,  cold  or  heat 
applied  to  the  abdomen.  This  variation  in  consistence  is  one  of 
the  most  important  signs  of  pregnancy.  It  may  also  be  found  in 
the  rare  condition  of  the  uterus  distended  with  blood,  sometimes 
in  a  soft  myoma,  or  in  a  greatly  distended  bladder.  The  round 
ligaments  may  sometimes  be  palpated  in  pregnancy ;  most  fre- 
quently, however,  in  labor.  They  can  best  be  felt  in  thin-walled 
multiparas  by  passing  the  fingers  from  the  flanks  downward  and 
forward.  The  higher  the  fundus  the  more  distinct  are  the  ridges 
formed  by  them.  When  the  uterus  is  rotated,  that  one  which  is 
most  anterior  is  usually  most  prominent.  The  elevated  ovary  and 
tube  may  sometimes  be  palpated,  especially  on  one  side,  if  moved 
anteriorly  by  rotation  of  the  uterus. 

Fetal  parts  can  rarely  be  palpated  through  the  abdomen  satis- 
factorily before  the  sixth  month.  In  the  late  months,  if  there  be 
not  excessive  liquor  amnii,  if  the  abdominal  wall  be  thin  and 
relaxed  and  the  uterus  soft,  various  parts  of  the  fetus  may  be 
felt — /.  e.,  breech,  head,  trunk,  limbs.  When  fetal  movements 
take  place  the  hand  may  usually  feel  them.  In  the  fifth  month 
they  are  not  very  distinct,  being  compared  to  a  throb.  Later 
they  are  recognized  as  a  gliding  of  the  body,  head  or  breech 
under  the  hand,  as  a  series  of  thrusts  when  the  limbs  strike  out- 
ward, or  as  combinations  of  these  when  movements  are  very 
vigorous.  Often  they  may  be  started  or  made  more  noticeable 
by  the  application  of  cold  or  by  deep  palpation.  Frequently 
no  movements  may  be  felt  during  a  period  of  several  hours  or 
even  days  ;  their  absence,  therefore,  does  not  mean  a  dead  child 
or  negative  pregnancy.  Movements  may  be  simulated  by  con- 
tractions in  the  abdominal  muscles  or  by  the  passage  of  gas 
through  the  intestines. 

On  percussion  of  the  abdomen  in  pregnancy  a  dull  note  is 
obtained  over  that  portion  of  the  wall  of  the  uterus  which  is  in 
direct  contact  with  the  anterior  wall  of  the  uterus.  Above  this 
the  note  is  resonant  where  the  intestines  come  into  relation  with 
the  fundus.  Very  rarely  the  intestines  may  descend  low  in  front 
of  the  uterus,  leading  to  altered  percussion-findings. 

Fetal  Heart. — The  fetal  heart  sounds  become  audible  usually 
between  the  eighteenth  and  twentieth  weeks,  when  they  may  often 
be  heard  through  a  stethoscope  applied  near  the  fundus  of  the 
uterus.      Rarely  they  may  be  distinguished  three  or  four  weeks 


122  DIAGNOSIS   OF   UTERINE  PREGNANCY. 

earlier.  In  the  late  months  it  is  heard  when  the  back  of  the 
fetus  is  within  reach  of  the  stethoscope ;  in  head  presentations 
below  the  level  of  the  umbilicus ;  in  breech  presentations  above. 
The  sound  is  compared  to  the  distant  ticking  of  a  watch  under  a 
pillow.  The  rate  averages  about  130  per  minute,  the  ordinary 
range  of  variation  being  between  120  and  150.  Naegele  found 
the  minimum  rate  to  be  90,  and  the  maximum  180  in  600  cases. 
It  is  usually  about  twice  the  maternal  heart  beat. 

Variations  may  be  noted  from  time  to  time  in  the  same  fetus. 
Frankenhauser  believed  that  sex  could  be  determined  by  the  rate, 
males  having  a  slow  heart  and  females  a  rapid  one.  This  is  a 
vety  unreliable  sign,  for  although  the  rate  varies  inversely  with 
the  size  of  the  fetus,  a  large  female  could  not  be  diagnosed  from 
a  small  male.  The  causes  of  all  variations  are  not  well  known. 
The  rate  is  increased  by  active  movements  and  by  elevation  of 
maternal  temperature.  It  slows  in  the  early  stages  of  fetal 
asphyxiation  and  increases  toward  the  end  of  the  process.  In 
labor  it  rises  as  the  pain  begins,  and  slows  toward  the  period  of 
maximum  intensity,  when  the  heart  may  sometimes  momentarily 
cease.  Interference  with  the  cord  slows  the  heart  and  makes  the 
sounds  weaker.  The  heart  may  be  inaudible  or  faint  in  a  healthy 
fetus  when  its  back  is  turned  toward  the  back  of  the  mother,  in 
hydramnios,  when  the  abdominal  wall  is  thick,  when  the  placenta 
is  situated  anteriorly,  or  when  the  sound  is  masked  by  the  noise 
of  gas  in  the  maternal  intestines,  by  the  uterine  souffle,  or  by 
sounds  in  the  examiner's  ear.  Failure  to  hear  the  heart,  even  on 
successive  occasions,  is  not  alone  conclusive  of  death  of  the  fetus. 
When  the  fetus  is  very  feeble  its  heart  may  be  heard  with  dif- 
ficulty. Ordinarily  a  rate  lower  than  120  must  be  regarded  as 
dangerous,  especially  if  irregular.  Several  simulations  of  the 
fetal  heart  sounds  must  be  remembered.  Thus,  the  ear  may 
mistake  maternal  pulsations  for  them.  In  ordinaiy  circum- 
stances the  error  may  be  detected  by  placing  a  finger  on  the 
mother's  radial  pulse  and  noting  its  rate.  If  the  latter  be  ver}^ 
much  quickened  from  excitement,  fever,  prolonged  labor,  or  loss 
of  blood,  it  may  be  difficult  to  distinguish  maternal  from  fetal 
sounds. 

Uterine  Souffle. — This  term  is  applied  to  a  soft  blowing 
murmur,  synchronous  with  the  maternal  pulse,  heard  in  the  lower 
abdominal  region.  According  to  Depaul  it  first  develops  after 
the  tenth  week.  It  is  usually  best  heard  about  the  seventh 
month,  and  is  rarely  ever  absent.  It  is  most  distinct  over  the 
broad  ligaments  close  to  the  uterus,  being  often  more  distinct 
on  one  side  than  on  the  other.  It  may  frequently  be  heard  also 
over  a  portion  of  the  uterine  wall,  especially  when  the  placenta  is 
situated  anteriorly.  The  sound  is  caused  by  the  flow  of  blood 
through  enlarged  arteries  in  the  broad  ligament  and  is  not  due  to 


UTERINE   SIGNS.  123 

pressure  of  the  stethoscope.  Pressure  may  make  it  disappear. 
In  some  cases  a  thrill  is  felt  by  the  hand  placed  on  the  abdomen. 
Kiwisch  states  that  sometimes  a  souffle  may  be  caused  by  the 
epigastric  arteries.  The  uterine  souffle  may  often  be  intensified 
by  placing  the  woman  in  the  genupectoral  posture.  It  may  be 
heard  after  the  death  of  the  fetus,  and  often  after  delivery. 
Sometimes  it  is  faint,  at  other  times  well  marked  ;  it  is  most 
evident  in  anemic  w^omen.  It  gradually  disappears  in  the  puer- 
perium.  A  similar  souffle  may  be  heard  in  some  cases  of  ectopic 
pregnancy,  and  in  conditions  of  enlarged  uterus  not  associated 
with  pregnancy — /.  e.,  fibromyoma.  Herman  and  Champneys 
state  that  the  souffle  of  pregnancy  is  higher  in  pitch  than  that  of 
uterine  tumors. 

Funic  Souffle. — This  term,  first  used  by  Kennedy  in  1833,  is 
applied  to  a  murmur  heard  through  the  uterine  wall,  synchronous 
with  the  fetal  heart  beat ;  it  is  rarely  obtained.  It  is  believed  to 
be  produced  by  pressure  of  the  stethoscope  on  the  umbilical  cord 
when  the  latter  rests  against  the  fetus  close  to  the  uterus. 
Frankenhauser  states  that  it  is  caused  by  winding  of  the  cord 
around  parts  of  the  fetus,  by  knots  in  the  cord,  and  by  prolapse 
of  the  cord.  In  some  cases  the  souffle  is  not  derived  from  the 
cord,  but  is  produced  by  the  fetal  heart  valves  and  transmitted 
through  the  uterine  wall ;  thus  it  may  be  caused  by  fetal  cardiac 
disease  or  by  various  temporary  conditions. 

Fetal  Shock. — This  term  is  applied  to  the  sounds  produced 
by  movements  of  the  fetus  as  heard  by  the  examiner's  ear.  Con- 
tractions of  fetal  muscles  begin  about  the  tenth  week.  The 
sounds  produced  by  movements  of  the  limbs  or  body  cannot  be 
heard  before  the  fourteenth  or  fifteenth  week,  when  they  resemble 
a  faint  thud  or  irregular  tapping.  In  cases  where  the  abdominal 
wall  is  thick  or  the  liquor  amnii  abundant  the  sounds  may  not  be 
distinguished  at  this  early  date.  Movements  of  gas  and  liquid  in 
the  intestine  may  be  mistaken  for  them ;  very  rarely  the  bubbling 
of  gas  due  to  decomposition  in  the  liquor  amnii. 

Uterine  Sigfns. — The  various  signs  presented  by  the  uterus 
on  abdominal  examination  after  the  fourth  month  of  pregnancy 
have  already  been  described.  In  the  early  months  also  important 
points  are  to  be  noted.  On  inspection  the  cervix  is  seen  to  have 
a  purplish  hue.  This  varies  in  intensity  and  in  the  time  of  com- 
mencement ;  ordinarily  it  is  faintly  marked  early  in  the  second 
month.  On  bimanual  examination  the  cervix  feels  softer  than  in 
the  non-pregnant  state.  This  is  usually  first  recognized  early  in 
the  second  month,  the  softening  appearing  to  be  superficial.  As 
pregnancy  advances  more  of  the  thickness  of  the  cervix  is 
affected.  In  cases  in  which  there  has  been  marked  induration  of 
the  cervix  as  a  result  of  old  inflammation  there  may  be  very  little 


124  DIAGNOSIS   OF   UTERINE   PREGNANCY. 

change  in  consistence.  As  a  rule,  the  softening  proceeds  slowly 
until  the  sixth  month  ;  afterward  it  advances  more  rapidly. 

As  a  result  of  these  changes  the  cervix  becomes  less  easily 
definable  toward  the  end  of  gestation,  and  to  the  examining 
fingers  may  seem  to  be  shortened.  (See  p.  9(S.)  During  the 
last  few  weeks  the  canal  of  the  cervix  is  usually  patulous.  In 
primiparae  this  is  true  of  the  lower  portion  ;  in  multiparae  often 
of  the  whole  extent.  In  the  former  the  os  internum  remains 
small ;  in  the  latter  it  is  frequently  so  patulous  as  to  admit  a 
finger-tip.  In  the  diagnosis  of  pregnancy  too  much  importance 
must  not  be  paid  to  the  condition  of  the  cervix  in  the  early 
months.  In  the  late  weeks  a  very  soft  and  somewhat  patulous 
state  is  strongly  suggestive  of  pregnancy. 

The  body  of  the  uterus  in  the  early  months  of  pregnancy 
becomes  characteristically  altered.  It  enlarges  and  becomes 
somewhat  globular.  It  varies  in  consistence,  being  at  one  time 
soft  and  difficult  to  outline,  at  another  doughy  and  boggy,  and 
when  contractions  are  present  in  the  musculature  hard  and  non- 
elastic.  In  the  first  two  or  three  weeks  these  changes  are  recog- 
nized with  much  greater  difficulty  than  in  later  weeks,  so  that  in 
the  earliest  stage  it  is  rarely  possible  to  diagnose  pregnancy 
absolutely  from  the  bimanual  examination  alone.  After  the  early 
part  of  the  second  month  the  increase  in  size  of  the  body  is 
generally  felt  as  a  bulging  through  the  anterior  fornix  ;  this,  of 
course,  is  absent  when  the  uterus  is  retroverted  or  retroposed. 
On  abdomino-vaginal  or  abdomino-rectal  examination  the  wall  of 
the  uterus  close  to  the  cervix  is  usually  so  soft  and  compressible 
that  the  opposed  fingers  appear  almost  to  meet.  This  is  known 
as  Hegar's  sign  ;  in  a  small  percentage  of  cases  it  is  not  well 
marked  or  only  partially.  It  is  best  obtained  during  the  second 
and  third  months.  Braun-Fernwald  has  emphasized  the  import- 
ance of  asymmetry  of  the  uterus  as  distinguished  by  bimanual 
examination.  This  sign  is  undoubtedly  frequently  present,  one 
half  of  the  body  appearing  to  be  larger  and  softer  than  the  other ; 
a  longitudinal  depression  may  also  be  felt  between  the  two 
portions.  This  condition  may  often  be  detected  by  the  end  of  the 
first  month.  The  explanation  of  this  sign  is  undoubtedly  the 
development  of  the  ovum,  in  such  cases,  more  in  one  half  of  the 
uterine  cavity  than  in  the  other.  In  describing  the  anatomy  of  the 
uterus  I  have  stated  that  between  the  globular  condition  of  the 
body  in  the  fourth  month  and  the  pyriform  shape  of  the  late 
months  there  is  an  intermediate  stage,  when  the  fundus  begins  to 
enlarge  at  the  beginning  of  the  fifth  month.  At  this  time,  on 
careful  examination,  the  commencing  upward  elevation  of  the 
fundus  may  be  distinguished  if  the  conditions  be  favorable  to  easy 
palpation.  This  stage  is,  however,  a  very  short  one,  as  the  fundal 
enlargement  soon  broadens. 


DIFFERENTIAL   DIAGNOSIS    OF  PREGNANCY.  1 25 

Ballottement  is  the  movement  of  the  fetus  or  parts  of  the 
fetus  in  the  amniotic  fluid,  by  the  fingers  appHed  to  the  abdominal 
or  vaginal  wall.  The  whole  fetus  may  be  thus  moved  by  external 
manipulations,  especially  in  the  fourth  and  fifth  months.  After- 
ward, usually  only  some  part  of  the  fetus — /.  e.,  head,  breech, 
limb,  may  be  moved.  During  the  ninth  month,  when  the  liquor 
amnii  is  relatively  diminished,  it  is  not  easy  to  obtain  ballottement. 
The  movements  are  obtained  when  the  woman  lies  on  her  back 
or  side.  The  fetal  part  may  sometimes  be  pushed  from  one  hand 
to  the  other ;  or  it  may  be  moved  by  a  sudden  jerk  of  the  fin- 
gers, returning  against  them.  When  the  fetus  is  very  large  or 
the  uterus  greatly  distended  by  hydramnios  or  twin  pregnancy 
ballottement  is  rarely  obtained.  Ballottement  may  be  simulated 
by  palpation  movements  of  a  wandering  spleen,  kidney,  liver,  or 
of  a  pedunculated  cystic  or  solid  tumor  in  the  abdomen. 

Internal  ballottement  is  obtained  by  pressing  one  or  two 
fingers  against  the  anterior  vaginal  wall,  giving  a  sudden  mov^e- 
ment  to  that  part  of  the  fetus  lying  against  the  anterior  uterine 
wall.  The  fetus  rises,  and  may  or  may  not  settle  down  again  in 
its  former  position.  This  sign  is  best  obtained  during  the  fifth 
and  six  months.  It  is  absent  in  the  early  months,  when  the  fetus 
is  very  small,  and  in  the  advanced  months,  when  the  liquor  amnii 
is  diminished  in  quantity.  To  examine  the  patient  most  satis- 
factorily she  should  be  placed  in  a  sitting  or  half-sitting  posture. 
Ballottement  may  be  simulated  by  palpation  of  pelvic  tumors, 
especially  if  complicated  with  fluid  accumulations,  kidney  pro- 
lapsed into  pelvis,  stone  or  tumor  in  the  bladder,  and  by  marked 
pulsation  in  the  fornix  vaginae. 

_  Vaginal  Signs.— By  the  end  of  the  first  month  slight  dark- 
ening of  the  vaginal  walls  is  often  noticed,  due  to  increased  con- 
gestion of  the  tissues.  In  many  cases  this  change  begins  at  later 
periods.  Chadwick  states  that  it  is  noticed  in  80  per  cent,  of 
women  by  the  end  of  the  third  month.  As  pregnancy  advances 
the  color  of  the  walls  becomes  deep  violet,  changing  more  to  blue 
in  the  late  months.  These  changes  were  first  described  by 
Jacquemin.  In  a  {(t\N  cases  there  may  be  few  color  changes. 
The  wall  becomes  softer  as  pregnancy  advances,  and  pulsation  of 
arteries  may  be  felt  distinctly  by  the  examining  finger,  especially 
near  the  fornix.  The  vulva  also  becomes  softer  and  darker  in 
color  and  is  more  freely  moistened  than  in  the  non-pregnant 
state. 

DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY. 

In  :^arly  Pregnancy.— Metritis. — A  uterus  enlarged  by 
chronic  inflammation  may  be  mistaken  for  pregnancy,  especially 
if  menstruation  has  been  irregular  or  if  one  or  more  periods  have 
been   missed.     The  metritic  uterus  does  not  vary  in  consistence 


120  DIAGNOSIS    OF   UTERINE   PREGNANCY. 

like  the  pregnant  uterus,  nor  is  there  any  softening  above  the 
cervix.  In  cases  of  doubt  it  is  necessary  to  wait  several  weeks 
in  order  to  determine  whether  or  not  the  progressive  increase 
in  the  size  of  the  uterus,  characteristic  of  pregnancy,  takes 
place. 

Myoma. — An  interstitial  submucous  fibroid  may  simulate  the 
pregnant  uterus,  especially  if  the  fibroid  be  soft.  There  is,  how- 
ever, usually  no  amenorrhea.  There  may  have  been  a  history  of 
previous  abortions  or  of  sterility.  In  doubtful  cases  examination 
must  be  made  at  intervals  of  a  few  weeks  in  order  to  determine 
the  rate  of  growth.  The  pregnant  uterus  grows  much  more 
rapidly  than  a  fibroid.  Sometimes  an  early  pregnant  uterus  may 
bleed  and  simulate  a  fibroid.  Marked  hemorrhage  is  especially 
found  when  there  is  a  placenta  prsevia  or  when  there  is  a  threat- 
ened abortion  from  any  cause. 

In  early  pregnancy  asymmetiy  of  the  uterus  is  occasionally 
noted  when  the  ovum  develops  near  one  Fallopian  tube,  especially 
in  cases  of  a  slightly  marked  bicornute  condition.  For  a  short 
while  the  uterus  may  be  thought  to  be  a  fibroid,  a  fibroid  and 
pregnancy,  or  an    ectopic   gestation  may  be   suspected.     (See  p. 

325-) 

Enlarged  Ovary  or  Tube. — An  ovarian  cystoma  or  an  en- 
larged ovary  containing  any  kind  of  fluid,  or  a  distended  tube,  if 
adherent  to  the  uterus  or  pressed  closely  against  it,  may  be  mis- 
taken for  a  pregnant  uterus.  This  is  especially  apt  to  be  the  case 
if  the  uterus  is  retroverted  and  the  swelling  is  situated  in  front 
and  adherent  to  the  uterus.  The  alternate  hardening  and  relaxa- 
tion of  the  latter  are  wanting  in  the  mass,  and  progressive  increase 
in  size  as  rapid  as  that  of  the  pregnant  uterus  is  rarely  found. 
Menstruation  is  not  likely  to  be  absent. 

Ectopic  Gestation. — Various  forms  of  ectopic  pregnancy  are 
apt  to  be  mistaken  for  uterine  pregnancy.     (See  p.  416.) 

Distended   Bladder. — A  bladder  more  or  less  distended  with 
urine   may  simulate  the  pregnant   uterus.      If,  however,  a   high 
rectal  examination  be  made  the  uterus  is  found  displaced  back 
ward.     In  all  doubtful  cases  the  bladder  should  be  catheterized. 

Hematometra. — A  uterus  distended  by  blood  may  closely 
simulate  pregnancy.  As  the  condition  is  caused  by  atresia  in  or 
below  the  cervix,  its  nature  should  easily  be  established.  When 
there  is  atresia  of  one  half  of  a  septate  uterus  the  condition  may 
be  more  puzzling  and  requires  the  most  thorough  study. 

In  Advanced  Pregnancy.— Obesity.— A  fat  abdominal 
wall,  especially  if  protuberant  or  associated  with  separation  of  the 
recti  muscles  and  enteroptosis,  may  sometimes  simulate  the  en- 
largement of  pregnancy,  especially  if  there  be  amenorrhea.  Some 
degree  of  resonance  may  be  obtained  on  percussion.  The  chief 
signs  of  gestation — /.  c,  fetal  heart,  fetal  movements,  fetal   parts, 


DIFFERENTIAL   DIAGNOSIS   OF  PREGNANCY.  12/ 

ballottement,  are  absent.  The  cervix  is  not  soft  and  the  vagina 
not  discolored. 

Flatulent  Distention  of  the  Abdomen — This  condition  is 
similarly  distinguished  from  the  enlargement  of  pregnancy.  (See 
Pseudocyesis,  p.  138.) 

Ascites. — Distention  of  the  abdomen  by  free  ascitic  fluid,  unac- 
companied by  new  growths,  is  very  rarely  mistaken  for  pregnancy. 
The  characteristic  signs  of  ascites  are  not  found  in  the  latter  con- 
dition. They  are  as  follows  :  bulging  and  dulness  in  the  flanks, 
resonance  in  the  upper  middle  portion  of  the  belly  as  the  patient 
lies  on  her  back,  change  in  the  area  of  dulness  as  the  patient 
moves  her  position.  When,  however,  ascites  is  accompanied  with 
new  growths — /'.  c,  fibroids,  ovarian  tumors,  or  with  tuberculous 
masses  of  bowel  or  omentum,  the  latter  may  be  mistaken  for  fetal 
parts  and  ballottement  may  be  obtained.  If  there  be  amenorrhea 
the  simulation  of  pregnancy  may  be  marked.  There  are,  how- 
ever, no  active  movements,  no  fetal  heart  sounds,  and  no  varia- 
tions in  the  sac  containing  the  fluid.  The  simulation  of  pregnancy 
is  intensified  if  the  ascitic  fluid  be  loculated,  especially  if  mesially 
placed. 

Uterine  Tumors — A  large  sohd  fibroid,  especially  a  soft 
myoma,  may  closely  resemble  the  pregnant  uterus.  A  souffle 
may  be  present,  the  vagina  and  cervix  may  be  congested  and 
darkened,  and  the  consistence  of  the  tumor  may  vary.  Some- 
times a  submucous  fibroid  may  be  felt  inside  a  patulous  cervix 
and  may  be  mistaken  for  the  head  or  breech  of  the  fetus.  There 
is  usually,  however,  no  amenorrhea,  but  rather  menorrhagia  or 
metrorrhagia.  But,  above  all,  the  chief  signs  of  pregnancy — viz., 
those  related  to  the  fetus,  are  absent. 

When  the  tumor  is  partially  cystic  the  resemblance  to  the 
pregnant  uterus  may  be  very  close.  When  several  fibroids  are 
present,  irregular  in  shape  and  pedunculated,  they  may  be  mis- 
taken for  the  fetal  parts  and  ballottement  may  be  simulated,  espe- 
cially if  ascites  be  present.  Sometimes  in  such  cases  the  patient 
may  feel  the  tumors  move  when  she  changes  her  position,  and 
she  may  regard  them  as  active  fetal  movements.  When  uterine 
fibroids  are  associated  with  pregnancy  the  condition  may  be  mis- 
taken even  after  the  most  careful  examination.  Most  frequently 
the  pregnancy  is  overlooked. 

Ovarian  Tumors. — A  large  ovarian  cystoma  may  simulate  the 
enlarged  pregnant  uterus,  especially  when  it  lies  mesially  and  when 
the  uterus  is  so  displaced  as  not  to  be  felt  bimanually.  The  wall 
does  not  undergo  alternate  hardening  and  relaxation,  a  souffle  is 
very  rarely  heard,  and  no  fetal  heart  sounds  are  present.  Occa- 
sionally projecting  secondary  cysts  may  simulate  fetal  parts,  but 
there  is  rarely  a  simulation  of  ballottement.  Menstruation  is  not 
usually  absent,  or  if  it  is  there  is  usually  a  history  of  gradual  dis- 


128  DIAGNOSIS   OF   UTERINE   PREGNANCY. 

appearance  and  anemia.  Sometimes,  however,  the  tumors  may 
be  found  in  a  period  of  amenorrhea  associated  with  the  meno- 
pause. 

Malignant  tumors  of  the  ovary  ma}^  also  simulate  pregnancy. 
The  author  once  saw  a  }-oung  girl  with  an  abdominal  swelling 
in  whom  there  were  man}-  secondary  signs  of  pregnane)-.  The 
swelhng  closely  resembled  a  pregnant  uterus,  though  no  fetal 
signs  were  found.  She  had  never  menstruated.  On  abdominal 
section  the  mass  was  found  to  be  a  soft  sarcoma  of  the  ovar}'. 
Malignant  ovarian  growths  accompanied  by  ascites  may  simulate 
pregnancy,  as  described  above. 

Parovarian  Cyst. — When  such  a  cyst  is  large,  occupying  the 
lower  abdominal  region,  it  may  also  be  mistaken  for  a  pregnant 
uterus,  especially  if  the  uterus  may  be  so  displaced  as  not  to  be 
palpated.  Its  wall  is  very  thin  and  does  not  vaiy  in  consistence, 
and  fluctuation  may  usually  be  readily  obtained.  Fetal  signs  are 
entirely  wanting  and  menstruation  is  rarely  absent. 

Other  Abdominal  Tumors — A  hydatid  cyst  may,  like  an 
ovarian  cyst,  simulate  the  pregnant  uterus,  especially  if  it  develop 
in  the  pelvis  and  enter  into  close  relationship  with  the  uterus. 
Malignant  omental  and  mesenteric  growths  are  rarely  mistaken 
for  the  pregnant  uterus.  If  ascites  be  present  there  may  be  a 
simulation,  the  growths  being  mistaken  for  fetal  parts.  An 
enlarged  spleen  may  descend  into  the  pelvis  and  may  sometimes 
be  mistaken  for  pregnancy.  As  a  rule,  the  signs  and  symptoms 
associated  with  the  enlargement,  and  the  extension  of  the  swelling 
under  the  ribs  on  the  left  side,  suffice  to  establish  its  nature. 

Ectopic  Gestation. — Various  forms  of  advanced  ectopic  preg- 
nancy ma)'  simulate  uterine  gestation.     (See  p.  416.) 

In  all  the  above-mentioned  conditions  that  may  simulate  uter- 
ine pregnancy,  few  or  many  of  the  normal  signs  and  symptoms 
of  gestation  may  be  present — /.  r.,  mammary  changes,  nausea, 
pigmentation,  discoloration  of  the  vagina,  an  enlargement,  some- 
times progressive  and  rapid,  etc.  In  some  instancess  ballottement 
may  be  felt.  Sometimes  the  mother  may  state  that  she  feels 
movements.  In  all  cases  systematic  investigation  and  thorough 
physical  examination  are  essential.  Abdominal  palpation  and  the 
rectovaginal  abdominal  bimanual  should  always  be  employed.  In 
every  case  of  doubt  the  patient  should  be  studied  under  anesthesia. 
When  there  is  no  urgency,  and  in  the  majority  of  cases  there  is 
none,  repeated  examination  at  intervals  of  a  few  A\'eeks  may  be 
necessary.  Very  rarely  is  an  exploratory  incision  required  in 
order  to  establish  the  diagnosis.  This  should  be  done  when  it 
is  felt  that  the  patient  ma)'  be  endangered  by  allowing  the  condi- 
tion which  is  confounded  with  pregnancy  to  continue,  especially 
if  it  should  prove  to  be  of  such  a  nature  as  to  require  treatment 
by  abdominal  section. 


LENGTH   OF  GESTATION. 


CHAPTER    IV 


129 


LENGTH   OF  GESTATION;   CALCULATION  OF   THE 
DURATION  OF  PREGNANCY. 

I^ength  of  Gestation. — The  average  duration  of  pregnancy 
is  ordinarily  considered  to  be  280  days,  40  weeks,  9  calendar 
months,  or  10  lunar  months.  It  is  impossible  to  be  accurate  in 
any  given  case,  because  the  exact  time  of  conception  is  not 
known.  There  are  no  symptoms  by  which  this  process  is  made 
known  either  to  the  mother  or  to  the  physician.  Conception  may 
closely  succeed  insemination  or  may  not  follow  it  for  several  days. 
Active  spermatozoa  may  hve  in  the  Fallopian  tubes  for  three  weeks. 
We  are  ignorant,  moreover,  regarding  the  place  of  fertilization  of 
the  ovum  in  any  given  case,  and,  if  fertilized  in  the  tube,  do  not 
know  how  long  it  may  take  to  reach  the  uterine  mucosa.  It 
seems  undoubted  there  are  considerable  variations  in  the  normal 
length  of  pregnancy,  the  reasons  being  not  understood.  In  some 
women  it  may  be  habitually  longer  or  shorter  than  the  average. 
It  is  believed  by  some  that  the  duration  of  pregnancy  is  apt  to  be 
short  at  the  beginning  and  the  end  of  the  reproductive  era  and 
longer  in  the  mid-period.  It  is  also  stated  to  be  shorter  in  single 
than  in  married  women. 

Issmer  states  that  the  duration  of  pregnancy  increases  with  each 
child  up  to  the  ninth,  after  which  there  is  a  decrease.  He  also 
says  that  the  average  is  a  little  greater  in  strong  women  than  in 
those  who  are  weak.  Some  authorities  hold  that  it  is  greater  in 
women  who  rest  a  great  deal  during  pregnancy  than  in  those 
who  work. 

In  the  domestic  animals  observations  seem  to  show  that  the 
length  of  pregnancy  has  a  normal  range  of  variations.  Thus, 
Tessier  found  it  to  be  in  mares  311  to  394  days  ;  in  cows  241  to 
308  days.  Various  calculations  have  been  made  as  to  the  occur- 
rence of  labor  after  a  single  coitus.  The  average  varies.  Matthews 
Duncan  found  it  to  be  275  days  in  46  cases  ;  Lowenhardt  272.2 
in  578  cases;  Ahlfeld  271  in  425  cases, the  difference  between  the 
longest  and  shortest  being  99  days.  Hecker  found  the  average  to 
be  273.5  days,  the  difference  between  the  longest  and  shortest  being 
63  days. 

Viability  of  the  Fetus. — The  eariiest  period  at  which  the  fetus 
is  viable — /.  c,  may  survive,  is  not  definitely  known.  Many 
instances  are  recorded  in  which  the  exact  ages  of  fetuses  which 
have  lived  are  given,  but  the  figures  must  be  regarded  as  only 
approximately  accurate,  since  the  exact  age  cannot  be  estimated 
either   by  maternal    or   fetal    data.       The   consensus   of  medical 


130  LENGTH  OF  GESTATION. 

opinion  favors  the  view  that  a  fetus  born  before  the  one  hundred 
and  fiftieth  day  cannot  be  viable,  and  that  it  is  not  Hkely  to  hve  in 
the  majority  of  cases  if  born  before  the  latter  part  of  the  seventh 
lunar  month. 

In  the  case  of  labors  during  the  last  month  of  pregnancy,  mis- 
takes are  doubtless  often  made  in  diagnosing  as  short  and  normal 
those  pregnancies  that  are  really  premature  from  abnormal  (but 
often  unknown)  causes.  Careful  study  of  the  fetus  may  help  in 
deciding  the  true  nature  of  such  cases,  but  owing  to  the  variations 
in  the  size  and  development  of  the  fetus  it  is  not  possible  to  form 
an  accurate  conclusion. 

The  law  with  regard  to  children  born  before  the  full  term 
varies  in  different  countries.  In  France  and  Italy  one  born  within 
180  days  after  marriage  can  be  repudiated  by  the  husband  if  there 
has  been  no  intercourse  between  him  and  his  wife  before  marriage. 
In  Scotland  a  birth  6  months  after  marriage  is  considered  legal. 
In  England  and  America  no  limit  is  fixed. 

Protracted  Gestation. — Many  cases  of  prolonged  pregnancy 
have  been  recorded,  most  of  which  have  been  calculated  from  a 
single  coitus  or  from  death  or  absence  of  the  husband.  Sir  J.  Y. 
Simpson  published  an  account  of  four  cases  in  which  labor  oc- 
curred respectively  336,  332,  319,  and  324  days  after  the  cessa- 
tion of  menstruation.  Puppe  has  reported  a  case  in  Avhich  the 
duration  of  pregnancy  was  estimated  at  348  days.  These  and 
other  similar  statistics  are  open  to  the  criticism  that  the  calcula- 
tions based  upon  menstrual  data  or  the  time  of  coitus  may  be 
quite  fallacious. 

In  a  number  of  cases  in  which  pregnancy  was  believed  to  be 
protracted  the  fetus  was  above  the  average  weight,  but  whether 
this  is  always  found  is  not  known.  It  is  difficult  to  form  con- 
clusions from  the  size  of  the  child,  because  normally  it  may  vary 
considerably.  Some  authorities  have  reported  cases  in  which  at 
the  expected  time  of  confinement  ineffective  labor  pains  have  come 
on  and  passed  away,  the  actual  deliver}^  taking  place  a  month  later. 
Of  course,  in  these  instances  error  may  have  been  made  in  the 
calculation,  and  the  threatening  of  labor  may  have  taken  place 
not  at  term  but  a  month  beforehand.  It  cannot  be  denied,  how- 
ever, that  a  true  "  missed  labor  "  may  sometimes  occur. 

The  law  regarding  protracted  pregnancy  varies  in  different 
countries.  In  France  legitimacy  cannot  be  contested  until  300 
days  have  passed  after  death  of  the  husband  or  the  last  oppor- 
tunity for  coitus.  The  law  is  the  same  in  Austria.  In  Prussia 
it  is  301  days.  In  England  and  America  there  is  no  fixed  date. 
In  one  State  in  the  latter  country  there  has  been  a  legal  decision 
in  favor  of  .3 17  days.  In  England  a  child  born  304  days  after 
separation  of  the  parents  has  been  held  as  legitimate. 

Calculation  of  the  Probable  Date  of  Delivery. — Various 


CALCULATION  OF  DATE    OF  DELIVERY.  13I 

methods  are  employed  to  calculate  the  time  of  labor,  all  of  which 
are  apt  to  be  fallacious  and  inaccurate. 

Cessation  of  Menstruation. — Some  authorities  have  been 
accustomed  to  estimate  the  probable  date  of  labor  by  counting 
from  the  end  of  the  last  menstrual  period.  Thus,  Matthews 
Duncan,  having  noted  that  the  average  interval  between  the  ces- 
sation of  menstruation  and  labor  was  278  days,  adopted  the  fol- 
lowing method :  "  Find  the  day  on  which  the  female  ceased  to 
menstruate,  or  the  first  day  of  being  what  she  calls  '  well.'  Take 
that  day  nine  months  forward  as  275,  unless  February  is  included, 
in  which  case  it  is  taken  as  273  days.  To  this  add  3  days  in  the 
former  case,  or  5  if  February  is  in  the  count,  to  make  up  278. 
This  two  hundred  and  seventy-eighth  day  should  then  be  fixed 
on  as  the  middle  of  the  fortnight  in  which  the  confinement  is 
likely  to  occur,  by  which  means  allowance  is  made  for  the  average 
variation  either  of  excess  or  deficiency."  Naegele's  method,  the 
one  most  commonly  employed,  consists  in  fixing  a  date  2S0  days 
from  the  first  day  of  the  last  menstruation.  One  may  count  9 
months  ahead  or  go  back  3  months  and  add  the  number  of  days 
necessary  to  make  the  total  of  280  days.  For  7  months  in  the 
year  7  days  (in  leap  years  after  February  6  days)  are  added.  In 
February  4  days,  in  December  and  January  5  days,  and  in  April 
and  September  6  days  only  are  necessary. 

Lowenhardt  bases  his  method  upon  the  view  that  pregnancy 
corresponds  to  10  menstrual  intervals  of  28  days  each.  He  states 
that  variations  in  the  duration  of  pregnancy  depend  upon  the 
length  of  the  interval,  and  to  estimate  the  expected  labor  he 
multiplies  the  interval  by  10.  Thus,  the  ordinary  interval  is  28, 
and  this  multiplied  by  10  amounts  to  280.  These  methods  are 
not  accurate.  When  they  were  introduced  it  was  believed  that 
ovulation  always  occurred  at  menstruation.  Now  we  know  that 
an  ovum  may  escape  from  the  ovary  at  any  time  during  or  between 
menstruation.  It  is  also  known  that  conception  may  occur  imme- 
diately after  the  last  menstruation  or  just  before  the  period  that 
should  next  take  place.  Moreover,  it  is  certain  that  one  or  more 
menstrual  discharges  may  sometimes  occur  after  conception  has 
taken  place.  Consequently  errors  may  result  from  calculations 
based  on  the  menstrual  data,  amounting  to  a  few  days  or  3  or  4 
weeks.     Lowenhardt's  method  is  most  unreliable. 

In  many  cases  menstrual  data  are  of  no  avail — /.  e.,  when 
conception  occurs  before  menstruation  has  begun,  in  the  dodg- 
ing periods  of  puberty  and  the  menopause,  in  conditions  of 
amenorrhea  due  to  various  causes,  in  cases  in  which  the  men- 
strual function  is  irregular.  When  discharges  of  blood,  menstrual 
or  pathologic,  escape  from  the  uterus  after  conception  has  taken 
place  the  calculation  is  likely  to  be  fallacious. 

Coitus. — Reference  has  already  been  made  to  the  calculation 


132  CALCULATION  OF  DATE    OF  DELIVERY. 

of  the  duration  of  pregnancy  by  counting  from  a  single  coitus, 
and  the  fallacies  have  been  mentioned. 

Quickening. — Calculations  based  on  the  time  of  quickening 
are  very  fallacious.  The  time  varies  considerably  in  different  cases 
(see  p.  1 15),  though  on  the  average  it  may  be  said  to  occur  about 
mid-term. 

Size  of  the  Uterus. — The  size  of  the  uterus  at  different  periods 
of  pregnancy  has  already  been  described.  (See  page  93.)  In 
ordinary  practice  it  is  usual  to  estimate  the  period  of  pregnancy 
by  determining  the  relationship  between  the  fundus  of  the  uterus 
and  the  pelvic  brim,  and  between  the  fundus  and  the  umbilicus. 
These  methods  are  only  approximately  accurate.  The  navel 
varies  considerably  in  position  and  should  not  be  regarded  as  a 
fixed  point,  especially  in  multiparae.  Then  there  are  variations  in 
the  position  of  the  fundus,  due  to  the  tonicity  of  the  abdominal 
wall,  the  amount  of  liquor  amnii,  the  size  and  number  of  fetuses, 
the  relationship  of  different  viscera,  pathologic  conditions,  etc. 

Mensuration  of  the  Fetus. — Measurement  of  the  fetal  el- 
lipsoid is  made  to  determine  the  stage  of  pregnancy  in  the  later 
months.  Ahlfeld  has  pointed  out  that  the  full  length  of  the  fetus 
is  about  double  the  head  to  breech  measurement  in  the  normal 
attitude  of  flexion.  To  obtain  this  measurement  it  is  necessary 
to  use  calipers,  placing  one  pole  on  the  abdomen,  against  the 
upper  end  of  the  fetal  mass,  and  the  other  in  the  cervix,  care 
being  taken  to  make  the  fetus  lie  vertically.  As  such  a  procedure 
may  be  inconvenient,  the  method  has  been  adopted  of  measuring 
from  the  top  of  the  pubes  to  the  upper  end  of  the  fetal  pole,  since 
this  is  about  the  same.  In  advanced  gestation  the  measurement 
is  said  to  correspond  to  the  number  of  lunar  months  passed. 

This  method  gives  only  approximately  accurate  results.  The 
size  of  the  fetus  varies  considerably.  Thus,  at  full  time  it  may 
measure  from  vy\  to  19I  in.  in  length.  Sutugin  gives  the  follow- 
ing measurements : 

Lunar  month.  Length  of  fetal  elUpsoid. 

Seventh 7.6  in. 

Eighth 8.3  in. 

Ninth 9.2  in. 

Tenth , 9.7  in. 


MULTIPLE   PREGNANCY.  1 33 

CHAPTER   V. 

MULTIPLE  PREGNANCY, 

Twins. — Statistics  as  to  multiple  pregnancies,  furnished  by- 
different  European  and  American  countries,  vary.  On  the  average 
twin  gestation  may  be  said  to  occur  about  once  in  every  80  or  90 
pregnancies. 

Causes. — The  explanation  of  twin  conception  is  probably  to 
be  explained  by  atavism,  a  reversion  to  an  arrangement  found  in 
the  lower  mammals.  Such  a  view  is  strengthened  by  the  occa- 
sional occurrence  of  a  multiple  gestation  both  in  the  tube  and 
uterus.  In  the  great  majority  of  cases  it  occurs  in  the  uterine 
cavity. 

The  condition  appears  to  be  more  common  in  some  districts 
than  in  others.  Thus,  in  Ireland  it  is  more  frequently  found  than 
in  England  or  Scotland.  It  is  often  a  hereditary  peculiarity,  being 
transmitted  through  the  males  or  females,  sometimes  in  successive 
generations,  sometimes  at  intervals.  Twins  are  commonest  in  primi- 
parae,  especially  in  those  who  are  elderly.  Sir  Arthur  Mitchell  has 
pointed  out  their  frequent  occurrence  in  families  which  produce 
idiots,  imbeciles,  and  those  with  deformities — /.  e.,  spina  bifida, 
club-foot,  etc. 

Varieties. — Twins  are  binovular  or  uniovular. 

I.  Binovular. — These  arise  from  the  fertilization  and  develop- 
ment of  two  ova.  They  may  be  derived  from  one  ovary,  each 
being  in  an  independent  Graafian  follicle ;  they  may  be  contained 
in  one  Graafian  follicle ;  or  each  ovum  may  come  from  a  separate 
ovary.  They  may  both  develop  in  the  normal  uterus,  one  in  each 
horn  of  a  bicornute  uterus,  both  in  one  Fallopian  tube,  one  in 
each  tube,  or  one  in  the  uterus  and  one  in  a  tube.  In  the  present 
description  reference  will  be  made  only  to  the  cases  in  which  both 
develop  in  the  normal  uterus. 

Binovular  twins  are  about  six  times  as  frequent  as  the  uniovular 
variety,  and  are  to  be  regarded  as  more  normal  than  the  latter. 
They  may  occur  at  any  period  of  the  reproductive  life.  The  chil- 
dren are  often  carried  to  term  and  born  healthy.  Their  combined 
average  weight  is  greater  than  in  the  case  of  uniovular  twins. 
Their  sex  may  be  the  same,  but  often  it  is  different.  Rumpe  has 
shown  that  in  10 1  cases  of  binovular  twins,  both  children  were 
males  in  31  and  females  in  16;  while  in  54  each  sex  was  repre- 
sented. 

Relationship  in  Fetal  and  Maternal  Structures. — Each  ovum 
is  usually  covered  in  the  early  stages  of  development  with  its 
own  reflexa.     It  is  also  believed  that  both  may  sometimes  develop 


134  MULTIPLE   PREGNANCY. 

under  a  common  reflexa.  In  advanced  gestations  it  is  not 
possible  to  decide  regarding  the  early  reflexal  relationships. 
Each  ovum  develops  a  separate  chorion.  These  may  remain 
distinct  throughout  pregnancy,  or  blending  of  adjacent  portions 
may  occur,  the  joined  part  disappearing,  so  that  a  common 
chorionic  sac  may  be  formed.  There  is  also  at  first  a  separate 
amniotic  cavity  for  each  embryo.  Very  rarely  there  may  be  a 
disappearance  of  the  contiguous  portions  of  the  sacs,  giving  rise 
to  one  amniotic  cavity.  In  such  a  case  evidence  of  the  double 
origin  may  be  found  on  careful  search.  Each  fetus  has  a  distinct 
placenta.  These  may  sometimes  be  so  close  together  as  to  make 
it  appear  as  if  there  is  only  one  large  single  placenta.  The 
independence  of  the  two  parts  is  shown  in  the  absence  of  any 
anastomosis  between  the  fetal  vessels.  Anomalous  insertions  of 
the  cord  and  placenta  succenhiriata  are  not  infrequent  in  twin 
cases. 

2.  Uniovular. — Uniovular  twins  arise  from  one  ovum.  In 
some  cases  two  blastodermic  areas  are  formed,  each  of  which 
develops ;  in  others  there  may  be  a  single  blastodermic  area, 
which  divides,  each  forming  a  fetus.  Uniovular  twins  are  to  be 
considered  as  decidedly  abnormal.  They  are  born  prematurely 
much  more  frequently  than  the  binovular  variety,  and  if  they 
reach  full  term  are  apt  to  be  weak  and  ill  developed.  Abnor- 
mality of  one  fetus  is  very  common  in  uniovular  twin  pregnancy, 
hydramnios  being  usually  found  with  it.  Uniovular  twins  are 
always  of  the  same  sex.  Their  frequency  is  believed  to  be  about 
1 5  to  20  per  cent,  of  all  twin  cases. 

Relationship  of  Fetal  and  Maternal  Strnctiires. — In  the  case 
of  uniovular  twins  there  is  always  one  reflexa  and  one  chorion. 
There  may  be  a  single  amnion  or  each  fetus  may  have  its  own 
amniotic  sac.  Ahlfeld  says  that  the  former  condition  is  found 
only  in  8  per  cent,  of  cases.  The  placenta  is  single  and  generally 
large.  The  umbilical  cords  may  enter  it  separately  or  united. 
Usually  an  anastomosis  can  be  made  out  between  the  two  sets  of 
fetal  vessels  under  the  amniotic  covering  of  the  placenta. 

Course  and  Complications. — Twins  often  show  disparity  as 
regards  size,  development,  and  vitality.  The  difference  may  be 
slightly  or  strongly  marked.  The  explanation  is  not  fully  under- 
stood, though  one  important  factor  is  the  nature  of  the  blood 
supply  to  each  fetus  ;  it  is  not,  however,  always  possible  to  state 
wherein  the  nutritional  difference  exists.  One  fetus  may  some- 
times be  nourished  by  a  much  larger  chorionic  area  than  the 
other  after  the  degeneration  of  the  chorion  laeve.  There  may  be 
a  difference  in  some  cases  in  the  nature  of  the  vascularization  of 
the  maternal  decidua  related  to  each  chorion  frondosum.  Degen- 
erative changes  may  be  more  marked  in  the  villi  connected  with 
one    fetus    than    in    those    beloncrincr    to    the    other.     Structural 


TWINS.  135 

peculiarities  in  the  embryo  may  also  partly  explain  differences  in 
growth  and  development.  There  may  be  a  faulty  development 
in  one  cord.  In  the  case  of  uniovular  twins  the  anastomosis  of 
the  fetal  vessels  may  be  such  as  to  favor  one  fetus  more  than  the 
other. 

In  some  instances  the  less  fortunate  fetus  perishes,  and  if  it  lies 
in  its  own  amniotic  sac  it  may  be  expelled  from  the  uterus,  the 
other  fetus  developing  to  full  time ;  in  some  cases  its  death  may 
be  followed  by  expulsion  of  the  entire  uterine  contents.  Fre- 
quently neither  of  these  results  is  found,  as  the  dead  fetus  may 
remain  in  the  uterus  and  form  with  its  own  placenta  and  mem- 
branes a  mole,  or  it  may  be  pushed  and  flattened  by  the  pressure 
of  the  ovum  which  continues  to  develop  so  as  to  form  the  so- 
C2i\\&dfcettis  papyraccus.  Very  rarely  one  of  a  pair  of  twins  con- 
tained in  a  single  amniotic  cavity  may  be  thus  changed,  the  other 
continuing  to  develop.  Death  of  the  fetus  is  much  more  common 
in  the  case  of  uniovular  than  in  the  case  of  binbvular  twins. 
Occasionally  one  of  a  pair  of  uniovular  twins  develops  in  a 
peculiar  relationship  to  the  other  as  a  result  of  the  nature  of  the 
anastomosis  between  the  fetal  vessels.  The  better-developed 
embryo  has  the  stronger  circulation,  which,  through  the  anasto- 
mosis, interferes  with  the  circulation  connected  with  the  weaker 
embryo,  which  it  gradually  uses  to  a  great  extent  for  itself.  The 
heart  of  the  weaker  embryo  gradually  atrophies  as  a  result  of 
this  arrangement.  The  upper  part  of  its  body  does  not  develop, 
but  becomes  a  shapeless  mass.  The  lower  part  of  the  body  may 
develop  so  that  the  legs  are  recognizable,  since  its  nourishment 
continues  because  of  the  circulation  of  blood  through  its  umbili- 
cal vessels.  The  embryo  thus  altered  is  known  as  the  acardiac 
fnonster ;  it  is  a  mere  appendage  to  the  healthy  fetus. 

Very  rarely,  when  twins  are  alive  and  unequally  developed, 
one  may  be  expelled  from  the  uterus  some  weeks  before  the 
other,  which  continues  to  develop.  This  probably  only  happens 
when  the  amniotic  cavities  are  distinct,  especially  in  the  case  of 
a  malformation  of  the  uterus  marked  by  its  division  into  halves. 
Premature  complete  emptying  of  the  uterus  is  believed  to  occur 
in  more  than  60  per  cent,  of  twin  cases. 

Hydramnios  is  often  found  in  twin  gestations,  and  hydatidi- 
form  degeneration  of  the  chorion  is  not  infrequent.  Placental 
infarcts  of  various  sizes  are  common.  Faulty  conditions  of  an 
umbilical  cord  may  be  present.  Sometimes  the  cords  of  twins  in 
one  amniotic  sac  become  knotted  or  twisted  and  may  thus  lead  to 
their  death.  Fetal  malformations  may  be  found  especially  in  the 
case  of  uniovular  twins.  Eclampsia,  albuminuria,  and  edema  of 
the  suprapubic  cutaneous  tissue  and  of  the  lower  limbs  are  fre- 
quent. At  full  time  the  fetuses  are  unusually  equal  in  size,  the 
average  weight  being  9I  pounds,  the  weight  of  each  varying  from 


136  MULTIPLE   PREGNANCY. 

3  to  7  pounds.  In  about  65  per  cent,  of  cases  twins  are  of  the 
same  sex,  these  being  all  the  uniovular  and  some  of  the  binovular. 
In  slightly  more  than  50  per  cent,  of  the  cases  in  which  the  sex 
is  the  same  the  twins  are  male ;  in  a  little  less  than  50  per  cent, 
they  are  females. 

Diagnosis. — The  diagnosis  is  often  uncertain,  and  may  not  be 
estabUshed  until  labor  occurs.  In  pregnancy  twins  may  be  sus- 
pected from  unusual  size  of  the  uterus.  This  has  no  positive 
value,  however,  since  it  may  be  due  to  a  large  fetus,  excessive 
liquor  amnii,  or  a  tumor.  A  large  uterus  without  excessive  amni- 
otic fluid,  in  which  there  is  limited  mobility  of  the  fetus  and  an 
unusual  number  of  projecting  fetal  parts,  is  strongly  suggestive 
of  twin  gestation.  The  information  to  be  derived  from  palpation 
and  auscultation  is  most  important.  Sometimes  a  sulcus  may  be 
felt  in  the  uterine  wall  between  the  two  fetuses.  This  is  often 
absent  and  may  be  due  to  other  causes.  The  outlining  of  two 
distinct  fetal  heads  or  two  backs  is  an  important  sign.  Ahlfeld 
states  that  if  two  fetal  poles  are  found  more  than  1 1|  in.  apart  in 
advanced  pregnancy,  there  is  a  strong  probability  of  the  presence 
of  twins.  The  detection  of  two  fetal  heart  sounds  in  different 
positions,  especially  if  they  differ  in  rhythm,  is  conclusive.  Of 
course,  different  heart  sounds  may  never  be  heard  in  some  twin 
pregnancies,  even  where  both  fetuses  are  alive,  owing  to  their 
disposition  ;  or  only  one  may  be  heard,  because  of  the  death  of 
one  fetus. 

Disposition  of  the  Twins. — At  full  time  many  variations  are 
found  in  the  disposition  of  the  twins.  In  899  cases  of  labor 
tabulated  by  Kleinwachter  and  203  by  Reuss  the  presentation 
was  as  follows  :  Both  heads  in  49  per  cent. ;  head  and  breech  in 
3 1  per  cent. ;  both  breeches  in  8  per  cent. ;  head  and  breech  in 
6.18  per  cent.;  breech  and  transverse  in  4.14  per  cent.;  both 
transverse  in  0.35  per  cent.  The  transverse  presentations  were 
generally  secondary  to  sudden  emptying  of  the  amniotic  fluid  or 
birth  of  the  first  fetus,  the  uterus  being  large  and  relaxed. 

Triplets. — Triplets  are  said  to  occur  in  the  proportion  of  i 
in  6000  to  10,000  pregnancies.  They  may  develop  from  three  ova  ; 
two  may  develop  from  one  and  one  from  another ;  or  it  is  believed 
that  the  three  may  arise  from  one  ovum.  Walla  has  reported  a  case 
of  premature  labor  in  which  there  was  a  common  placenta  and 
chorion  and  three  separate  amniotic  sacs.  There  is,  therefore,  a 
difference  as  regards  the  relationships  of  placenta  and  membranes. 
Sometimes  one  or  two  of  the  fetuses  may  die  during  pregnancy, 
each  becoming  2ifcetns papyracciis. 

Quadruplets  and  quintuplets  are  very  rare. 

Superfecundation. — This  is  defined  as  the  fecundation  at  or 
near  the  same  time  of  two  separate  ova  by  two  separate  acts  of 
coitus.     This  appears  to  be  established  by  the  case  of  a  woman  who 


SUPER FE  TA  TION.  I  37 

had  intercourse  with  a  white  man  and  a  black  man  near  the  same 
time,  afterward  giving  birth  to  a  white  and  a  black  child.  Similar 
instances  have  been  noted  in  the  lower  animals.  Thus,  a  mare 
covered  by  a  stallion  and  by  an  ass  has  been  known  to  give  birth 
to  a  horse  and  a  mule  at  one  labor.  Superfecundation  probably 
accounts  for  a  number  of  binovular  pregnancies. 

Superfetation. — This  is  described  as  the  fertilization  of  two 
ova  at  different  periods,  one  occurring  some  time  after  the  other 
has  already  developed  to  a  certain  extent.  Those  who  believe 
this  possible  quote  the  following  in  proof — viz.,  the  delivery  of 
two  fetuses  at  different  degrees  of  development ;  the  delivery  of  a 
mature  child,  followed  after  some  months  by  one  equally  mature. 
Those  who  do  not  believe  in  superfetation  say  that  the  former  of 
these  occurrences  may  only  be  a  twin  conception,  one  ovum  being 
more  developed  than  the  other ;  in  the  second  instance  the  condi- 
tion may  be  that  of  a  double  pregnancy  in  a  septate  or  bicornu- 
ate  uterus.  An  interesting  case  of  this  nature  is  as  described  by 
Ross,  of  Brighton,  England.^  A  woman  had  a  miscarriage  of 
twins  on  July  16,  1870,  and  on  October  31  was  delivered  of  a 
well-developed  child.  In  this  case  there  was  a  complete  double 
uterus. 

The  occurrence  of  superfetation  in  a  single  uterus  has  been 
thought  possible  for  many  centuries.  The  Romans  had  laws  pre- 
scribing the  laws  of  succession  in  such  cases.  To  prove  it  beyond 
doubt  is  very  difficult,  and  such  an  instance  as  that  described  by 
Tyler  Smith,  at  first  sight,  appears  difficult  of  any  other  explana- 
tion. A  primipara  miscarried  at  the  end  of  the  fifth  month,  and 
a  few  hours  later  discharged  a  well-formed  ovum  of  about  one 
month.  Menstruation  had  occurred  regularly  during  the  preg- 
nancy. The  uterus  appeared  to  be  normal.  It  is  possible  in  such 
a  case  that  the  uterus  is  single  so  far  as  repfards  its  outer  contour, 
but  divided  by  a  septum  internally.  Such  a  condition  is  practi- 
cally the  same  as  the  bicornuate  uterus.  It  is  frequently  stated 
that  superfetation  is  impossible  because  ovulation  ceases  in  preg- 
nancy. While  this  is  usually  the  case,  there  are  exceptional  in- 
stances in  which  ova  are  shed.  It  is  also  said  that  ova  cannot 
reach  the  uterine  cavity  on  account  of  the  closure  of  the  uterine 
end  of  the  Fallopian  tube  by  the  development  of  the  decidua. 
There  is  no  proof  that  these  ends  become  so  occluded  as  not  to 
allow  an  ovum  to  enter  the  space  between  the  vera  and  reflexa, 
at  least  in  the  early  months.  Great  variations  are  found  as 
regards  the  time  of  obliteration  of  this  space.  It  has  also  been 
stated  that  the  thick  mucous  plug  in  the  cervical  canal  prevents 
the  spermatozoa  from  passing  up.  It  is  likely,  however,  that  they 
may  penetrate  mucus  in  the  pregnant  as  in  the  non-pregnant  state. 

1  Lancet,  1871,  vol.  ii.,  p.  188. 


138         HYGIENE   AND   MANAGEMENT  OF  PREGNANCY. 


CHAPTER   VI. 

PSEUDOCYESIS  (FALSE  OR  SPURIOUS  PREGNANCY). 

This  is  the  condition  in  which  a  woman  beHeves  herself  to  be 
pregnant,  though  no  conception  has  occurred.  It  may  be  found 
at  any  period  of  the  reproductive  hfe,  though  it  is  probably  most 
frequent  near  the  climacteric ;  it  is  not  infrequent  in  unmarried 
women  who  have  had  illicit  intercourse  and  fear  that  they  have 
been  impregnated,  or  in  young  married  women  who  are  very 
anxious  to  conceive.  In  many  cases  there  is  a  disturbed  mental 
state,  various  neuroses  being  manifested.  Sometimes  the  delusion 
may  be  fixed  and  retained  for  years.  Occasionally  marked  mental 
disorders  may  develop.  In  many  instances  the  simulation  of  preg- 
nancy may  be  most  marked,  various  signs  and  symptoms  being 
present — /.  r.,  cessation  of  menstruation,  morning  sickness,  changes 
in  the  breasts,  swelling  of  the  abdomen,  movements,  etc.  In  every 
case  careful  examination  should  be  carried  out  under  anesthesia, 
and  it  is  often  advisable  to  do  this  in  consultation,  in  order  to  give 
satisfactory  assurance  to  the  woman  as  to  her  condition.  In  a 
number  of  instances  pelvic  or  abdominal  diseases  may  be  found — 
i.  e.,  new  growths,  displacements,  inflammatory  swellings.  These 
may  be  large  enough  to  cause  abdominal  enlargement.  Some- 
times the  latter  is  merely  due  to  adiposity  ;  sometimes  to  relaxed 
parietes  with  enteroptosis.  Ascites  may  be  the  cause  of  enlarge- 
ment in  some  cases.  Occasionally  irregular  action  of  the  abdom- 
inal muscles  leads  to  the  appearance  of  a  swelling ;  frequently  it 
is  due  to  gaseous  distention  of  the  intestines.  Occasionally  a 
woman  with  the  delusion  of  pregnancy  may  have  a  spurious 
labor  when  she  believes  herself  to  be  at  full  term.  An  interest- 
ing historic  case  of  this  nature  was  that  of  Bloody  Mary,  Queen 
of  Eng-land. 


CHAPTER    VII. 

HYGIENE  AND  MANAGEMENT  OF  PREGNANCY. 

Care  of  the  Alimentary  Tract. — During  pregnancy  the 
diet  should  be  simple,  nutritious,  and  regular.  Heavy  breakfasts, 
late  suppers,  excessive  indulgence  in  tea,  coffee,  alcoholics,  indi- 
gestible and  rich  food,  should  be  avoided.  In  many  cases  women 
are  satisfied  with  the  ordinary  articles  of  diet.  Often,  however, 
there  is  marked  capriciousness,  and  it  may  be  difficult  to  satisfy 
their  peculiar  fancies  and  conform  to  a  normal  dietary.  It  is 
advisable  that  the  quantity  of  nitrogenous  matter  in  the  shape  of 


CARE    OF   THE   ALIMENTARY   TRACT.  1 39 

red  meats  should  be  strictly  regulated.  Indeed,  it  is  well,  as  a 
rule,  that  the  latter  should  not  be  taken  more  than  once  daily. 
Fruit,  vegetables,  and  liquids,  especially  milk,  should  be  freely 
allowed.  During  the  early  months,  when  nausea  exists,  it  may 
be  necessary  to  select  the  articles  of  food  with  great  care,  and 
occasionally  such  preparations  as  koumiss,  peptonized  food,  plas- 
mon,  beef  juices,  etc.,  can  alone  be  digested.  In  many  cases  the 
nausea  is  manifested  only  in  the  early  morning,  the  woman  being 
afterward  able  to  take  ordinary  meals. 

When  the  morning  sickness  is  very  troublesome  various  meas- 
ures may  be  adopted.  A  cup  of  cocoa,  chocolate,  coffee,  tea,  or 
beef  tea  may  be  given  before  the  woman  leaves  her  bed.  Some- 
times a  small  Seidlitz  powder  given  before  rising  will  control  the 
nausea.  Occasionally  a  small  dose  of  vin.  ipecac.  (TTLv.,  in  a  wine- 
glassful  of  water),  sipped  three  or  four  times  at  intervals  of  ten 
minutes,  may  be  beneficial.  Often  the  nausea  is  accompanied 
with  heartburn  and  acid  eructations.  In  this  condition  sodium 
bicarbonate  or  light  magnesia  is  valuable ;  sometimes  a  large 
dose  of  the  latter  at  bedtime  acts  satisfactprily.  When  there  is 
no  constipation  a  mixture  of  milk  and  Ume  water  is  often 
satisfactory. 

When  there  is  constipation  an  attempt  should  be  made  to 
change  the  habit  by  attention  to  the  dietary — /.  e.,  diminishing 
bread,  meat,  and  fluids  and  allowing  plenty  of  fruit  and  vege- 
tables. Sometimes  a  glassful  of  pure  water  or  of  salt  water  at 
bedtime  or  before  breakfast  suffices.  Well-salted  beef  tea  or 
chicken  tea  at  bedtime  may  also  be  used  for  the  same  pur- 
pose. When  dietetic  measures  fail,  laxatives  may  be  used — i.  e., 
pulv.  glycyrr.  co.,  mineral  waters  (Hunyadi  Janos),  cascara  sa- 
grada,  maltine  with  cascara,  sodium  phosphate,  etc.  Strong 
purgatives  should  not  be  used  save  when  other  agents  fail. 
Enemata  should  not  be  used  as  a  routine.  Occasionally  they 
may  be  used  when  the  lower  bowel  is  loaded  and  the  woman 
feels  uncomfortable.  For  this  purpose  one  or  two  cupfuls  of 
warm  Castile  soapsuds  or  of  warm  water  containing  a  little  salt 
may  be  used.  In  cases  where  the  nausea  is  very  bad  and  the 
patient's  strength  is  reduced,  it  is  necessary  to  use  such  measures 
as  lavage  of  the  stomach,  stimulation  by  champagne  or  brandy, 
rectal  feeding. 

Prochownick  urges  that  in  women  who  are  very  fat  the  abdom- 
inal muscles  are  apt  to  be  thin  and  the  uterine  musculature  weak 
in  labor.  He  advises,  therefore,  that  such  should  be  dieted,  so 
as  to  reduce  the  obesity,  massage  and  exercises  being  adopted 
to  improve  the  muscular  tone.  Women  reduced  by  diseases — 
/.  e.,  chlorosis,  by  previous  numerous  labors,  overwork,  bad  hygienic 
conditions,  etc.,  should  be  dieted  with  great  care,  so  as  to  improve 
their  health.     Frequently  a  few  weeks'  rest  in  bed  is  advisable, 


I40         HYGIENE   AND   MANAGEMENT   OF  PREGNANCY. 

light  massage  being  given  during  this  period.  In  those  who  have 
previously  been  unable  to  nurse  Prochownick  recommends  plenty 
of  carbohydrates  in  addition  to  the  ordinary  quantities  of  the  other 
constituents,  along  with  gentle  massage  of  the  breasts,  the  latter 
being  carried  out  during  the  six  weeks  before  labor. 

Kxercise. — Moderate  regular  exercise  is  valuable.  The 
woman  should  walk  in  the  open  air,  though  not  to  such  an 
extent  as  to  fatigue  herself.  In  warm  weather  she  should  as  well 
sit  outdoors  as  much  as  possible  or  drive.  Moderate  cycling  is 
allowable  in  the  early  months.  Horseback-riding,  driving  over 
rough  roads,  heavy  lifting,  straining,  hard  work,  must  be  avoided. 
The  rooms  in  which  she  lives  should  be  well  ventilated  both  night 
and  day.  Long  standing  on  the  feet  should  be  avoided.  Long 
railway  journeys  are  not,  as  a  rule,  advisable.  A  valuable  exercise 
for  pregnant  women  may  be  obtained  by  the  use  of  light  wooden 
dumb-bells,  or  by  the  movement  of  a  light  weight  suspended  over 
a  pulley.  In  some  cases  regular  daily  massage  of  the  limbs  is 
advisable  as  an  adjunct  to  other  exercises ;  it  is  very  beneficial, 
and  occasionally  may  be  the  only  exercise  permissible. 

Rest. — The  nightly  sleep  should  be  regular  and  undisturbed. 
It  is  often  advisable  to  supplement  this  by  a  nap  of  an  hour  or 
two  in  the  morning  before  the  midday  meal.  At  any  rate,  it  is 
advisable,  especially  during  the  second  half  of  gestation,  that  the 
woman  should  lie  for  an  hour  or  more  during  the  day  on  a  flat 
sofa  or  bed.  If  she  is  troubled  with  a  feeling  of  weight  and 
dragging  in  the  abdomen,  or  of  weakness,  pains,  or  cramps  in 
the  limbs,  great  relief  is  usually  given  by  rest  for  an  hour  or  more 
on  a  straight,  inclined  plane,  the  pelvis  being  twelve  or  eighteen 
inches  higher  than  the  head.  Sometimes  the  discomfort  most 
quickly  disappears  if  the  genupectoral  posture  is  adopted  for  a 
short  time. 

Clothingf. — The  clothing  should  not  constrict  the  chest  or 
abdomen  and  corsets  should  be  abandoned.  The  skirts  should 
be  suspended  directly  from  the  shoulders  or  from  a  loose  waist ; 
they  should  not  be  tied  in  the  ordinary  way  around  the  abdomen 
nor  allowed  to  drag  down  the  latter.  If  the  breasts  are  large  and 
heavy  they  may  be  prevented  from  dragging  by  a  well-adjusted 
supporter.  Whenever  the  abdominal  wall  is  lax,  the  linea  alba 
stretched,  and  the  recti  abdominis  muscles  separated,  a  well-fitting 
elastic  abdominal  binder  should  be  worn  when  the  woman  is  not 
lying  down.  It  should  extend  from  the  pubes  to  midway  between 
the  umbilicus  and  the  ensiform  cartilage.  It  may  be  kept  from 
slipping  up  by  rubber  bands  which  pass  around  the  thighs.  If 
these  cannot  be  worn  with  comfort,  garters  passing  from  the 
stockings  to  the  lower  edge  of  the  binder  along  the  front  of  the 
thighs  suffice  to  keep  it  in  position.  Constricting  garters  must  not 
be  worn  on  the  limbs.    The  stockings  may  be  suspended  from  the 


BA  THING—  URINAL  YSIS.  1 4 1 

abdominal  binder  if  the  latter  be  worn,  or  a  special  form  may  be 
worn  which  passes  around  the  hip. 

Bathing. — Daily  bathing  of  the  body  is  advisable.  The  water 
should  not  be  too  hot  or  too  cold;  a  temperature  of  75°  F.  is 
satisfactory.  The  bath  may  be  taken  at  bedtime  or  in  the  morn- 
ino-,  the  skin  beino;  well  rubbed. 

Care  of  the  Breasts. — The  breasts  and  nipples  must  be 
kept  clean ;  water  and  bland  soap  or  borax  (.5j  to  a  pintj  usually 
serve  for  this  purpose.  The  clothes  should  be  arranged  so  as 
not  to  press  against  the  nipples.  When  the  latter  are  small  or 
retracted  they  may  be  drawn  out  once  daily  during  the  last  two 
or  three  months  of  pregnancy,  clean  fingers  or  a  breast  pump 
being  used.  Hardening  agents,  such  as  alcohol,  should  not  be 
employed.  It  is  more  rational  to  keep  the  nipples  supple,  and  for 
this  purpose  lanolin  or  cocoa  butter  may  sometimes  be  used.  If 
the  colostrum  is  abundant  and  oozes  from  the  nipples  in  the  late 
months,  care  must  be  taken  to  place  absorbent  cotton  over  them 
and  to  prevent  them  from  becoming  covered  with  the  dried 
material. 

Care  of  the  Genitalia. — Vaginal  douches  are  not  necessary 
in  pregnancy  except  when  they  are  required  in  the  treatment  of 
some  pathologic  condition.  Some  women  are  in  the  habit  of 
washing  out  the  vagina  with  a  pint  of  warm  water  and  experience 
increased  comfort.  The  employment  of  antiseptic  douches  in 
pregnancy,  as  a  prophylactic  measure,  is  in  the  great  majority  of 
cases  unnecessary.  As  a  result  of  the  researches  that  have  been 
made  concerning  the  bacteriology  of  the  vagina  (see  p.  iii),  it 
is  established  that  there  is  a  normal  bactericidal  influence  exerted 
in  the  genital  canal  tending  to  produce  continued  asepticity,  and 
that  this  influence  may  be  considerably  weakened  by  the  chemical 
action  of  many  antiseptics. 

It  is  only  when  there  is  a  local  acute  or  chronic  infective  or 
venereal  process  on  the  vulva,  vagina,  or  cervix  that  antiseptics 
are  necessary  to  check  the  pathologic  process  and  to  destroy  the 
chances  of  a  fresh  infection  during  or  after  confinement.  Sexual 
intercourse  is  generally  regulated  by  the  inclinations  of  husband 
and  wife,  rarely  by  medical  considerations.  So  many  variations 
are  found  as  regards  this  habit  that  it  is  impossible  to  state  what 
should  be  the  limit  of  its  performance.  From  the  medical  stand- 
point it  is  reasonable  to  advise  moderation,  especially  when  the 
woman  has  suffered  from  previous  abortions,  and  abstinence 
during  the  last  month  or  two  of  pregnancy.  It  is  wise  also  to 
abstain  in  the  early  months  at  the  times  corresponding  to  the 
menstrual  period.  If  the  husband  shows  evidence  of  uncured 
venereal  disease,  coitus  should  be  prohibited  during  a  much 
longer   period. 

Urinalysis. — A  regular  monthly  examination  of  the  woman's 


142         HYGIENE   AND   MANAGEMENT   OF  PREGNANCY. 

urine  should  be  made  during  the  first  seven  months  of  pregnancy, 
and  afterward  once  a  week  or  fortnight.  The  total  amount  passed 
in  twenty-four  hours  should  be  noted  at  intervals.  The  quanti- 
tative estimation  of  urea  is  very  important.  Careful  qualitative 
and  microscopic  investigations  are  also  necessary. 

Psychic  State. — The  variations  in  the  mental  condition  of  a 
pregnant  woman  have  already  been  described.  It  is  necessaiy 
that  she  be  tenderly  and  tactfully  cared  for  and  .managed  by  her 
husband  and  friends.  Much  allowance  must  often  be  made  for 
her  peculiarities.  She  should  be  protected  from  worry,  shock, 
and  anxieties.  Her  environment  should  give  quietness,  cheerful- 
ness, and  freedom  from  excitement. 

Avoidance  of  Contact  with  Disease. — The  pregnant 
woman  should  be  protected  from  the  risk  of  contracting  the 
infectious  and  contagious  diseases,  both  for  her  own  sake  and 
that  of  the  fetus.  During  the  last  weeks  she  must  be  particularly 
careful  in  this  respect. 

Obstetric  Examination. — After  the  midterm  of  pregnancy 
the  physician  should  at  times  carefully  examine  the  abdomen  and 
pelvis  externally,  and  once  or  twice  should  make  a  thorough 
bimanual  examination.  The  knowledge  thus  gained  may  often 
prove  of  the  greatest  value  in  deciding  the  course  to  be  followed 
in  the  future  care  of  the  patient.  In  private  practice  there  is 
widespread  neglect  to  cany  out  systematic  physical  examination 
in  pregnancy,  and  the  resulting  misfortunes  are  consequently 
numerous.  The  investigation  is  made  to  determine  :  i,  Whether 
or  not  pregnancy  exists ;  2,  the  period  of  pregnancy  ;  3,  the  num- 
ber of  fetuses  in  utero ;  4,  the  attitude,  presentation  and  position, 
size  and  general  condition  of  the  fetus;  5,  the  existence  of  abnor- 
mal or  pathologic  changes  in  fetal  or  maternal  tissues  ;  6,  the  size 
and  shape  of  the  pelvis  ;  7,  the  probable  time  of  confinement ;  8, 
the  prognosis  in  the  case. 

Special  stress  must  be  laid  on  the  importance  of  obtaining 
information,  as  much  as  possible,  by  means  of  abdominal  palpa- 
tion, a  method  which  has  been  greatly  neglected  in  the  past. 
Experience  thus  gained  during  pregnancy  makes  it  more  easy 
for  the  practitioner  to  reduce  to  a  minimum  the  employment  of 
vaginal  examination  in  labor,  a  great  desideratum  from  the  stand- 
point of  aseptic  technic.  To  Pinard  is  perhaps  due  the  chief  credit 
for  developing  the  method  of  palpation  in  a  systematic  manner  in 
recent  times.  Munde,  Leopold,  Miillerheim,  Warden,  Maclennan, 
and  others  have  devoted  considerable  attention  to  it.  In  carrying 
out  palpation  the  patient  should  lie  on  her  back,  with  her  lower 
limbs  extended  and  slightly  abducted  and  her  arms  placed  along- 
side her  body.  The  bladder  should  have  been  recently  emptied. 
The  examiner's  hands  should  be  warm.  The  examination  should 
be  systematic.     Leopold  advises  beginning  with  the  fundus  and 


OBSTETRIC  EXAMINATION.  1 43 

moving  down  toward  the  cervix.  Pinard  recommends  examining 
the  lower  portion  first  and  the  fundus  last.  Usually  it  is  advisable 
in  the  very  beginning  to  move  the  hands  over  the  abdomen  simply 
to  accustom  the  patient  to  the  feeling.  Then  the  condition  of  the 
abdominal  muscles,  the  position,  outline,  size,  consistence,  etc.,  of 
the  uterus  may  be  determined.  An  endeavor  may  also  be  made 
to  map  out  the  placental  site,  round  ligaments,  and  ovaries.  The 
practitioner  may  then  stand  alongside  the  patient,  facing  her  pel- 
vis, and  may  place  a  hand  on  each  side  of  the  uterus  close  to  the 
pelvic  brim.  The  latter  should  be  palpated  as  far  as  possible  back- 
ward from  the  symphysis.  The  abdominal  wall  should  then  be 
pressed  inward  and  downward  in  order  to  determine  the  present- 
ing part  of  the  fetus  and  its  relation  to  the  pelvis.  If  the  former 
has  engaged  well  in  the  pelvis  the  inlet  is  felt  thus  occupied  by  a 
firm,  rounded  mass,  which  in  pregnancy  is  almost  certain  to  be 
the  head,  presenting  by  the  vertex.  Before  labor  the  trunk, 
breech,  or  face  is  practically  never  within  the  pelvic  cavity.  If 
the  presenting  part  be  at  the  brim  the  fingers  may  be  able  to 
palpate  it  to  a  large  extent  and  to  raise  it  from  the  brim.  It  may 
thus  be  possible  to  state  whether  it  is  a  head,  breech,  or  shoulder. 
If  it  be  a  head,  careful  palpation  should  be  made  to  determine  its 
size,  mobility,  exact  position,  etc.  When  neither  fetal  pole  lies  in 
relation  to  the  brim  the  fingers  of  both  hands  may  usually  deter- 
mine the  absence,  and  may  be  approximated  more  or  less  toward 
the  middle  line.  Sometimes  the  resistance  or  thickness  of  the 
abdominal  wall  makes  it  difficult  to  palpate  the  portion  of  the 
fetus  in  the  lower  part  of  the  uterus.  Similar  trouble  may  some- 
times be  caused  by  an  anterior  placenta  praevia,  distention  of  the 
bladder,  tenderness  due  to  various  inflammatory  conditions.  When 
the  fetus  is  premature  it  may  be  impossible  to  distinguish  the  head 
from  the  breech  ;  also  when  the  skull  is  macerated.  A  tumor  of 
the  uterus  or  neighboring  parts  may  interfere  with  palpation.  The 
middle  portion  and  fundus  of  the  uterus  should  then  be  palpated 
to  determine  the  body  of  the  fetus,  its  limbs,  and  upper  pole. 
When  the  breech  is  at  the  fundus,  it  is  felt  to  be  an  irregular 
mass  with  less  uniform  consistence  than  that  which  characterizes 
the  fetal  head.  Often  portions  of  the  limbs  are  felt  near  it ;  they 
are  usually  not  felt  when  the  fetal  back  Hes  directly  anterior.  In 
the  great  majority  of  full-time  cases  the  breech  lies  in  the  right 
half  of  the  fundus.  When  the  head  is  situated  at  the  fundus  the 
groove  of  the  neck  should  be  sought.  The  head  may  also  fre- 
quently be  made  to  move  somewhat  apart  from  the  body.  This 
is  not  the  case  with  the  breech.  When  the  back  is  palpated  it 
feels  firm  and  smooth.  Rarely  the  umbilical  cord  may  be  pal- 
pated between  the  back  of  the  fetus  and  the  anterior  uterine  wall. 
The  fetal  limbs  are  usually  most  accessible  in  dorsoposterior  posi- 
tions.    The  feet  are  usually  most  in  evidence  ;  they  respond  more 


144         HYGIENE   AND  MANAGEMENT  OF  PREGNANCY. 

markedly  than  the  upper  limbs  to  stimulation  of  the  fetus.  The 
many  other  conditions  which  may  be  determined  by  abdominal 
palpation  are  described  elsewhere  throughout  this  work. 

The  examination  in  pregnancy  should  include  careful  study  of 
the  bony  pelvis  and  genital  passage.  The  pelvis  of  every  primi- 
para  should  be  carefully  measured.  This  is  also  necessary  in 
multiparae  if  there  be  anything  in  the  previous  obstetric  history 
to  suggest  pelvic  abnormalities.  The  method  of  carrying  out  this 
examination  is  given  later.     (See  Chapter  on  Pelvic  Deformities.) 


PART   II. 

LABOR. 

CHAPTER  I. 

CLASSIFICATION   AJNTD   CLINICAX    PHENOMENA  OF 
NORMAL  LABOR. 

COMPARATIVE. 

Labor  is  more  difficult  and  serious  in  the  human  female  than 
in  other  animals.  This  is  due  to  several  causes,  chief  of  which 
is  the  peculiarity  of  the  human  pelvis  as  it  is  modified  for  the 
requirements  of  the  erect  posture.  In  all  mammals  below  man 
the  pelvic  cavity  is  practically  uncurved.  There  is  no  projecting 
sacral  promontory,  and  the  conjugate  diameter  is  greater  than  the 
transverse  at  all  levels.  As  the  diameters  do  not  change,  there  is 
no  necessity  for  such  movements  of  the  fetal  head  as  are  found  in 
human  labor.  The  pubic  symphysis  is  relatively  lower,  so  that 
the  conjugate  of  the  inlet  is  relatively  increased.  The  caudal  end 
of  the  spine  is  very  movable,  so  that  resistance  is  diminished  at 
the  outlet.  In  the  lower  mammals  the  pelvic  ligaments  and  articu- 
lations relax  markedly  in  pregnancy,  as  a  rule.  The  structures  of 
the  pelvic  floor  are  relatively  weaker  than  in  man  and  are  more 
easily  canalized.  There  is  less  tendency  to  lacerations  and  to 
tedious  labors.  The  fetal  head  is  relatively  small  and  somewhat 
conical,  and  is  usually  so  attached  to  the  spine  that  the  small  end 
is  anterior.  Malpresentations,  tumors,  and  fetal  complications  are 
rare.  The  placenta  is  much  more  easily  shed  among  the  great 
majority  of  animals  than  in  the  human  female.  There  is  no 
tendency  to  hemorrhage  or  sepsis.  Psychical  and  emotional  con- 
ditions exercise  little  or  no  influence.  It  is  interesting  to  note 
that  domestication  is  accompanied  by  increased  difficulties  in  the 
labor  of  animals.  Town-kept  and  stall-fed  horses  and  cattle  more 
frequently  need  help  than  those  living  on  the  plains.  Among  the 
more  primitive  and  barbarian  races  of  mankind  parturition  is  less 
complicated  than  among  the  civilized.  Though  the  pelvis  is  rela- 
tively smaller  among  them,  the  fetal  head  is  smaller  and  more 
conical.  The  more  artificial  and  luxurious  women  become,  the 
greater  is  the  percentage  of  abnormal  parturition. 

10  145 


140  CLINICAL   PHENOMENA    OF  NORMAL   LABOR. 

CLASSinCATlON  OF  LABORS. 

It  is  best  to  describe  labors  under  the  following  divisions  : 

1.  Natural,  those  in  which  the  cephalic  end  of  the  fetus  pre- 
sents at  the  brim  of  the  pelvis. 

2.  Preternatural,  those  in  which  the  breech  or  other  parts 
of  the  body  present.  They  may  divide  into  breech  and  transverse 
cases. 

3.  Anomalous  or  complex,  those  in  which  there  is  risk 
owing  to  fetal  or  maternal  complications. 

Natural  labors  may  be  subdivided  into  : 

{a)  Normal,  those  in  which  the  vertex  presents  and  labor  is 
finished  without  interference  within  twenty-four  hours. 

ib)  Morbid,  those  in  which  vertex  cases  are  delayed  or  in 
which  the  brow  or  face  presents.  These  are  prolonged  labors 
and  often  demand  artificial  delivery. 

It  is  very  evident  that  this  classification  is  imperfect,  but  the 
same  criticism  applies  to  all  that  have  been  introduced  into  obstet- 
ric literature.  One  that  would  satisfy  the  canons  of  logic  would 
be  too  unwieldy  for  practical  purposes.  The  one  chosen  is  simple 
and  may  serve  as  a  working-basis  for  the  student. 

CLINICAL  PHENOMENA  OF  NORMAL  LABOR. 

The  phenomena  of  labor  are  ordinarily  studied  in  three  parts  : 

Stage  I. — Canalization  or  dilatation  of  the  cervix  and  lower 
uterine  segment. 

Stage  II. — Expulsion  of  the  fetus. 

Stage  III. — Separation  and  expulsion  of  the  placenta  and  mem- 
branes. 

It  is  difficult  to  state  the  exact  time  of  the  commencement  of 
labor.  Clinically  it  is  usually  referred  to  the  first  appreciation  of 
the  pains  of  uterine  contractions  by  the  mother.  This  is  incorrect 
if  we  define  the  first  stage  as  that  in  which  dilatation  or  canaliza- 
tion of  the  cervix  and  lower  uterine  segment  is  brought  about,  for 
in  many  cases  some  degree  of  dilatation  may  be  developed  though 
no  pains  whatever  are  felt.  Moreover,  some  degree  of  dilatation 
may  take  place  in  certain  cases  during  the  last  days  or  weeks  of 
pregnancy,  the  mother  being  quite  unconscious  of  the  change. 
For  practical  purposes  the  division  of  the  phenomena  into  these 
three  groups  is  satisfactory.  Before  considering  them  in  detail, 
it  is  Avell  to  recapitulate  the  changes  that  are  usually  noted  prior 
to  the  characteristic  signs  and  symptoms  of  labor.  These  are 
variously  termed  "  premonitions,"  "  premonitory "  or  "  precur- 
sory "  signs  and  symptoms. 

During  the  last  weeks  of  pregnancy,  the  exact  period  varying 
in  different  cases,  the  soft  parts  of  the  pelvis  become  more  soft- 
ened and  relaxed.     In  primiparae  the  head  usually  descends  into 


FIRST  STAGE.  I47. 

the  pelvis;  in  multipara  it  lies  above  the  brim, though  the  fundus 
generally  sinks  slightly  downward  and  forward.  It  is  probably 
this  increased  downward  pressure  that  causes  increased  conges- 
tion, and  consequent  softening  of  the  pelvic  tissues,  by  transuda- 
tion of  serum  into  them.  It  is  also  a  common  cause  of  frequency 
of  micturition,  hemorrhoids,  and  difficulty  of  walking  during  the 
last  weeks  ;  occasionally  edema  of  the  lower  extremities  is  pro- 
duced. The  sinking  of  the  uterus  is  usually  associated  with  easier 
breathing  and  with  improved  gastro-intestinal  functions.  I  have 
already  referred  to  the  variations  in  the  size  of  the  cervical  canal 
that  may  be  found  during  the  last  weeks.  (See  p.  97.)  Women, 
especially  multiparae,  often  complain  of  dragging  and  aching  in 
the  pelvis,  chiefly  in  the  evening  hours.  These  have  been  termed 
dolor cs  presagientes.  The  phenomena  of  actual  labor  are  as  follows  : 


FIRST  STAGE. 

Uterine  Contractions. — The  painless  contractions  of  preg- 
nancy become  stronger,  and  in  the  great  majority  of  cases  cause 
the  woman  pain.  For  this  reason  the  term  "  true  pains  '"  is  used 
as  synonymous  with  "  contractions."  The  woman  becomes  more 
restless  and  likes  to  sit  down,  bend  forward,  or  to  press  on  her 
sacrum.  The  pain  is  felt  first  in  the  sacral  region,  gradually 
moving  around  toward  the  pubes.  They  begin  slowly,  increase 
in  intensity,  and  gradually  pass  off  At  first  the  intervals  may  be 
as  much  as  half  an  hour,  afterward  becoming  shorter.  It  may 
show  considerable  variations.  The  pains  are  involuntary  and  the 
woman  tends  to  complain  or  cry  out,  not  holding  her  breath  (as 
in  the  second  stage).  The  suffering  varies  in  different  cases. 
Differences  are  largely  dependent  upon  the  nervous  temperament 
of  the  woman,  though  they  are  also  related  to  variations  in  the 
physical  factors.  The  essential  suffering  is  due,  first,  to  the  con- 
traction of  the  uterine  muscle,  being  of  the  nature  of  the  pain 
caused  by  tetanic  contractions  or  cramps  in  other  hollow  viscera — 
/.  if.,  intestine,  bladder  ;  and  secondly,  to  the  stretching  of  the  cervix 
and  lower  uterine  segment. 

During  the  pains  the  uterus  grows  hard  and  erects  itself,  the 
fundus  moving  forward  from  the  spine.  The  maternal  heart  is 
quickened  and  that  of  the  fetus  slowed.  On  vaginal  examination 
during  a  pain  the  cervical  canal  is  stretched.  The  true  pains  of 
labor  must  be  distinguished  from  "  false  pains."  These  vary  in 
nature  and  quality.  They  may  be  short  and  sharp,  long  and  con- 
tinuous, or  irregular.  As  a  rule,  they  are  marked  by  irregularity. 
They  are  mostly  abdominal,  rarely  beginning  in  the  sacral  region 
and  moving  around  to  the  region  of  the  pubes.  They  may  be 
cau.sed  by  cramps  in  the  abdominal  wall,  intestine,  or  distended 
bladder ;    to  old  inflammatory  areas   within   the    abdominal  and 


148 


CLINICAL    PHENOMENA    OF  NORMAL   LABOR. 


pelvic  cavities.  They  are  frequent  in  cases  in  which  there  is 
marked  bowel  irregularity  and  in  conditions  of  overfatigue.  Some 
authors  believe  that  they  may  be  produced  by  irregular  contrac- 
tions of  portions  of  the  uterine  wall.  False  pains  may  be  mis- 
taken for  true  pains.  It  is  usually  said  that  they  may  be  distin- 
guished by  the  absence  of  stretching  of  the  cervical  canal  during 
the  pains,  but  this  is  a  very  unsatisfactory  test,  since  in  the  very 
beginning  of  labor  true  uterine  contractions  may  not  cause  any 
change  in  the  cervix  appreciable  by  the  finger.  One  important 
test  is  the  condition  of  the  uterine  body  during  the  pain.  If  there 
is  no  genuine  contraction,  it  will  not  become  hard  when  the  pain 
is  felt.  This  is  not  always  reliable,  however,  since  palpation  may 
be  unsatisfactory  on  account  of  the  woman's  nervousness,  sensi- 
tiveness, or  thickness  of  the  abdominal  wall.  If  the  cause  be 
contraction  of  part  of  the  uterus,  partial  hardening  may  be  felt. 

Dilatation  of  the  Cervix. — \\lth  the  recurrence  of  uterine 
contractions  dilatation  of  the  cen-ix  gradually  takes  place.     The 


Beginning  dilatation  of 
internal  os. 


Further    dilatation    of 
internal  os. 


Complete  eflacement  of 
i}iternal OS,  'with  sharji 
external  os. 


Fig.  69. — Diagram  showing  the  sensation  to  the  examining  finger  of  widening  and 
effacement  of  the  internal  os  during  dilatation  of  the  cervix,  and  the  knife-like  edge  of 
the  external  os  (one-half  natural  size). 

process  goes  on  from  above  downward.  If  a  finger  be  inserted 
into  the  cervical  canal,  the  bag  of  membranes  is  felt  to  grow  tense 
and  to  press  downward  firmly  against  the  cervix  and  adjacent 
part  of  the  lower  uterine  segment  during  a  pain,  becoming  relaxed 
when  the  pain  passes  off.  The  last  portion  to  be  canalized  is  the 
lower  end  of  the  cervix,  which  is  felt  as  a  thin  ring,  becoming 
larger  as  the  first  stage  advances.  In  many  multiparae  the  ring 
may  be  irregular  in  thickness  and  asymmetric  in  shape  as  a  result 
of  old  laceration  and  inflammation.  With  the  increase  in  size  of 
the  canal  a  larger  area  of  membranes  is  felt.  Ver>^  often  the 
mucous  discharge  is  tinged  with  blood  during  dilatation,  the 
blood  comins  from  the  area  from  which  the  membranes  become 


FIRST  STAGE.  1 49 

separated.  This  is  often  termed  "  the  show."  The  rate  of  dila- 
tation varies  greatly.  As  a  rule,  it  is  much  longer  in  primiparae 
than  in  multiparae.  It  is  more  rapid  in  the  late  than  in  the  earlier 
stages.  When  fully  canalized  the  diameter  of  the  os  externum 
should  measure  at  least  four  inches.  Reflex  vomiting  may  occa- 
sionally be  noticed  toward  the  end  of  dilatation. 

Formation  of  the  Bag  of  Membranes. — As  the  uterus 
contracts  the  force  is  distributed  at  right  angles  to  the  liquor 
amnii.  The  cervix  and  lower  uterine  segment  playing  practically 
a  passive  part,  and  the  cervical  canal  being  a  point  of  weakness  in 
the  containing  wall  of  the  amniotic  fluid,  it  is  easy  to  understand 
why  the  lower  pole  of  the  amniotic  sac  should  be  forced  down- 
ward. As  the  lower  segment  is  stretched  the  membranes  separate 
around  the  os  internum  as  a  result  of  the  disproportion  brought 


Fig.  70. — Form  of  membranes  during  dilatation,  watch-glass  (Varnier) :  the  presenting 
part  is  large  and  fills  the  cervix  (one-sixth  natural  size). 

about  between  the  membranes  and  uterine  wall.  As  labor  pro- 
ceeds the  area  of  separation  extends  upward  nearly  as  high  as  the 
retraction  ridge.  The  loosened  membranes  are  known  as  the 
"bag  of  waters"  or  "bag  of  membranes."  It  contains  liquor 
amnii,  above  which  is  the  fetal  head.  It  forms  a  hydrostatic  dila- 
tor when  the  force  of  uterine  contractions  is  transmitted  through 
it.  It  is  composed  of  amnion,  chorion,  and  decidua,  the  first 
being  the  toughest  and  most  important  element ;  the  central  por- 
tion is  often  composed  entirely  of  the  amnion,  the  chorion  and 
decidua  having  become  separated  from  it.  The  bag  may  roughly 
be  compared  to  a  saucer,  being  symmetrically  rounded.  Be- 
tween pains  it  is  lax  and  the  fetal  head  may  easily  be  felt  above 
it.  During  pains  it  bulges  down  and  becomes  very  tense  ;  in  this 
condition  it  may  not  be  possible  to  palpate  the  head.     In  abnormal 


ISO 


CLINICAL    PHENOMENA    OF  NORMAL    LABOR. 


cases  the  bag  of  membranes  may  pouch  through  the  cervix  some- 
what sausage-shaped ;  in  this  state  it  is  practically  useless  as  a 
dilator.  In  other  cases  the  membranes  do  not  separate  from  the 
uterine  wall,  and  thereby  cause  delay  in  labor. 


Fig.  71. — Form  of  membranes  with  less  efficient  filling  of  cervix  and  pelvis,  and  larger 
quantity  of  forewaters  (modified  from  Varnier). 

Rupture  of  the  Membranes. — This  occurs  at  various  times 
in  different  cases.  Generally  it  is  noticed  a  little  before  dilatation  of 
the  cervix  is  complete;  sometimes  at  the  end  of  dilatation.  In 
abnormal  cases  rupture  may  occur  prematurely  or  after  dilatation 


Fig.  72. — Glove-finger  form  where  the  presenting  part  is  small  (modified  from  Varnier). 


is  complete.  When  the  membranes  are  very  tough  and  do  not 
rupture  after  dilatation,  labor  is  delayed.  Rarely  they  may  not 
rupture,  but  may  become  greatly  stretched  over  the  advancing 
child,  being  born  intact.     The  rupture  is   usually  central,  but  it 


SECOND    STAGE.  151 

may  be  lateral ;  in  the  latter  form  the  rent  sometimes  extends 
around  the  bag,  so  that  the  latter  is  born  fitting-  over  the  head, 
and  known  popularly  as  a  "  caul."  Sometimes  a  lateral  tear 
occurs  prematurely,  leading  to  the  slow  escape  of  liquor  amnii,  a 
condition  sometimes  puzzHng  to  the  physician.  With  the  rupture 
there  is  the  escape  of  a  quantity  of  liquor  amnii.  The  head  then 
comes  in  contact  with  the  wall  of  the  canal,  acting  as  a  plug, 
whereby  the  rest  of  the  liquor  amnii  is  prevented  from  escaping. 

Rupture  of  the  membranes  must  not  be  described  as  deter- 
mining the  end  of  the  first  stage.  It  is  frequently  coincident  with 
the  completion  of  dilatation,  but  it  may  take  place  at  other  times. 
The  end  of  this  stage  is  best  described  as  the  completion  of 
canalization,  with  rupture  of  the  membranes.  A  patient's  state- 
ment regarding  rupture  is  not  always  reliable ;  the  dribbling  of 


FiG-  73-— Pear-shaped  pouch  seen  with  some  cases  of  macerated  fetus  (modified  from 

Varnier). 

urine  may  be  mistaken  for  it.  Rarely  there  is  an  accumulation  of 
fluid  between  the  amnion  and  chorion,  which  may  burst  and  be 
regarded  as  a  true  rupture. 

Accessory  Powers.— It  is  generally  taught  that  the  acces- 
sory muscles  are  not  brought  into  activity  during  the  first  stage 
of  labor.  While  they  play  no  part  in  dilating  the  cervix  and  ought 
to  be  inactive,  it  is  frequently  observed  that  they  are  employed  by 
the  patient  toward  the  latter  part  of  the  stage.  The  patient  may 
frequently  control  them  if  she  be  encouraged,  but  often  she  can- 
not do  so. 

SECOND  STAGE. 

Expulsion  of  the  Fetus.— Character  of  the  Pains.— After 
dilatation  of  the  cervix  and  escape  of  the  liquor  amnii  there  is  some- 
times a  pause  of  several  minutes,  in  which  the  patient  may  enjoy 
a  little  rest  or  fall  into  a  doze  ;  usually,  however,  the   pains  soon 


152  CLINICAL   PHENOMENA    OF  NORMAL    LABOR. 

return.  They  differ  in  character  from  those  of  the  first  stage.  The 
patient  tends  to  hold  her  breath  and  refrain  from  crying  out  as 
she  did  previously.  As  the  uterine  contraction  becomes  painful 
she  closes  the  glottis,  fixes  the  diaphragm,  and  brings  into  action 
the  abdominal  and  other  accessory  muscles  that  increase  intra- 
abdominal pressure,  the  viscera  being  forced  downward.  This  so- 
called  "  bearing-dowai  "  action  is  involuntary  in  character  and  may 
often  be  noticed  during  unconsciousness ;  it  may,  however,  be 
intensified  by  voluntary  effort  on  the  part  of  the  woman.  Indeed, 
she  often  desires  to  hold  firmly  to  something  with  her  hands, 
pressing  downward  with  her  feet,  thus  fixing  the  thorax  and  pelvis 
so  that  she  strains  as  in  the  act  of  defecation.  Among  many 
primitive  peoples  the  woman  sits  or  squats  in  the  very  position 
employed  during  the  latter  act.  In  civilized  countries  she  usually 
lies  in  bed  during  this  stage,  grasping  the  bedclothes  or  a  cloth 
tied  to  the  head  of  the  bed,  and  pressing  against  an  artificial  sup- 
port with  the  feet,  her  knees  being  drawn  up.  As  the  pain  passes 
off  she  frequently  cries  out.  The  uterine  contractions  usually 
become  more  severe  and  more  prolonged  as  the  second  stage  ad- 
vances ;  they  may  become  more  frequent,  especially  toward  the 
end.  Great  variations  are  found  in  these  conditions  in  different 
cases. 

Effect  of  the  Pains  on  the  Maternal  System. — Arterial  press- 
ure is  increased  during  the  pains.  The  pulse  rate  rises  until  the 
acme  of  a  pain  and  then  slows.  The  increase  may  be  largely  due 
to  fear,  suffering,  or  nervousness.  The  respirations  become  slower 
during  a  pain.  Urinary  excretion  is  increased  as  a  result  of  in- 
creased blood-pressure.  Some  authorities  state  that  the  tempera- 
ture rises  ;  others  deny  this.  It  is  not  strange  that  elevation 
should  take  place  from  marked  nervous  disturbance,  especially  in 
difficult  and  painful  labors. 

Advance  of  the  Head. — In  primipara^,  at  the  beginning  of  the 
second  stage  in  normal  cases,  the  head  is  usually  well  within  the 
upper  part  of  the  pelvic  cavity  ;  in  multiparae  the  vertex  is  at  or 
just  below  the  brim  level.  During  the  pains  the  head  advances 
little  by  little,  the  rate  varying  in  different  cases.  On  vaginal  ex- 
amination it  is  found  to  recede  between  them.  The  occipital  end 
gradually  rotates,  so  that  when  the  vulva  is  reached  the  posterior 
fontanel  is  in  the  middle  line.  As  the  head  advances  the  pubic 
segment  is  elevated  and  compressed  behind  the  symphysis ;  the 
sacral  segment  is  bulged  downward,  so  that  the  perineum  is 
stretched  in  all  directions  ;  its  anteroposterior  length  may  amount 
to  3  or  4  in.  At  the  same  time  the  anus  is  dilated  so  that  the  an- 
terior rectal  wall  is  exposed  ;  it  is  often  D-shaped,  the  flat  side  of 
the  letter  being  toward  the  vagina.  The  anteroposterior  diameter 
of  the  dilated  anus  may  be  an  inch  or  even  more. 

The  labia  majora  and  minora  are  flattened  out.     The  head  re- 


SECOND   STAGE. 


153 


mains  a  variable  time  at  the  pelvic  floor,  alternately  advancing 
during  the  pains  and  retreating  between  them,  as  a  result  of  the 
recoil  of  the  sacral  segment.  At  this  time  the  swelling  of  the 
scalp  over  the  posterior  fontanel — the  caput  succedaneum — be- 
comes more  developed,  being  most  marked  when  the  head  remains 
long  in  this  position.  As  the  head  descends  the  fundus  uteri 
sinks,  rising  again  as  the  head  recedes.  When  definite  advance 
through  the  vulva  takes  place  the  back  of  the  head  appears  under 
the  pubes,  followed  by  successive  portions,  the  sinciput  passing 
over  the  perineum,  followed  by  the  face.     This  is  usually  the  most 


Fig.  74. — Beginning  of  bulging  of  perineum  by  the  head,  which  is  visible  through  the 
vulvar  opening  (Bumm). 

painful  period,  the  action  of  the  accessory  muscles  being  generally 
vigorous  and  for  a  time  entirely  beyond  the  woman's  control.  In 
primiparae  the  hymen  and  fourchette  are  torn,  and  often  part  of 
the  perineum ;  in  multiparae  there  may  be  some  laceration,  but 
often  there  is  none.  The  head  becomes  cyanosed  during  a  pain  or 
continuously ;  if  the  latter,  it  must  be  regarded  as  an  indication 
that  the  cord  is  compressed  or  that  the  circulation  through  the 
placenta  is  seriously  interfered  with  by  abnormal  pressure  on  it 
or  by  separation  of  part  of  it. 

Immediately  after  the  birth  of  the  head,  or  succeeding  a  short 
interval,  pains  return.     The  head  is  noticed  to  rotate  so  that  the 


154 


CLINICAL    PHENOMENA    OF  NORMAL    LABOR. 


occiput  turns  to  one  side — usually  that  in  relation  to  which  it  was 
placed  in  the  uterus.  The  shoulders  are  next  born,  their  long 
diameter  being  anteroposterior,  and  afterward  the  body.  Then 
thei'e  is  a  gush  of  bloody  amniotic  fluid.  Usually  there  is  no  sign 
of  blood  until  the  child  is  born  unless  there  be  laceration  of  the 
cervix,  lower  uterine  segment,  or  vagina.  The  amount  of  blood 
mixed  with  the  liquor  amnii  varies.  It  is  usually  due  to  some 
laceration,  but  may  occasionally  be  due  to  separation  of  the 
placenta. 

It  is  interesting  to  note  the  relationship  of  the  fundus   and 


Fig.  75.- 


-Emergence  of  head  from  vulva.     The  caput  succedaneum  is  well  shown,  and 
also  dilatation  of  the  anus  (Bumm). 


upper  uterine  segment  during  the  second  stage.  The  latter 
becomes  elongated  in  its  anteroposterior  and  shortened  in  its 
transverse  diameter.  The  fundus  is  as  high  as  it  was  during  the 
first  stage,  or  even  a  little  higher,  until  the  head  has  begun  to 
escape  from  the  vulva.  These  changes  are  to  be  associated  with 
the  retraction  of  the  upper  uterine  segment,  the  diminution  of  the 
uterine  contents  as  a  result  of  the  escape  of  most  of  the  liquor 
amnii  after  rupture  of  the  membranes,  and  the  gradual  extension 
of  the  body  and  lower  extremities  of  the  fetus. 


THIRD  STAGE.  155 

THIRD  STAGE. 

Separation  and  Delivery  of  the  Placenta. — After  the 
birth  of  the  child,  accompanied  by  some  Hquor  amnii,  the  mother 
often  has  a  feeling  of  relief  and  is  inclined  to  rest  quietly.  Some- 
times she  may  complain  of  being  faint,  though  the  loss  of  blood 
may  be  small.  In  some  cases  there  may  be  a  chill  of  a  purely 
nervous  character. 

The  body  of  the  uterus  is  easily  felt  through  the  abdominal 
wall,  the  fundus  being  at  or  a  little  above  the  level  of  the  umbili- 
cus ;  it  is  of  firm  consistence,  though  not  hard,  as  during  a  period 
of  contraction,  and  may  be  indented  easily  with  the  finger.  Ordi- 
narily it  is  flattened  somewhat  anteroposteriorly  and  may  lie  sym- 
metrically or  obliquely.  After  an  interval  that  varies  from  a  few 
minutes  to  a  quarter  of  an  hour  or  more  uterine  contractions 
return,  causing  the  woman  pains.  The  body  of  the  uterus 
becomes  very  hard  and  sHghtly  reduced  in  size.  There  may  be 
a  series  of  these  pains  before  the  placenta  is  born,  some  blood 
escaping  at  the  same  time.  In  the  great  majority  of  cases  it 
presents  edgewise  ;  occasionally  by  its  fetal  surface.  Its  expulsion 
from  the  vagina  is  due  to  straining  efforts  that  the  woman  makes. 
These  may  be  partly  involuntary ;  sometimes  they  are  absent  and 
the  placenta  remains  undelivered  in  the  vagina.  Or  her  efforts 
may  be  unable  to  expel  it  while  she  lies  in  bed. 

In  some  instances  there  is  no  interval  whatever  between  the 
birth  of  the  child  and  the  expulsion  of  the  placenta,  one  following 
upon  the  other.  It  is  important  that  the  retracted  uterus,  before 
separation  of  the  placenta,  should  be  carefully  distinguished  from 
the  condition  in  which  the  placenta  lies  in  the  lower  uterine  seg- 
ment, cervix,  and  upper  part  of  the  vagina.  In  the  latter  case 
the  fundus  may  stand  as  high  or  even  higher,  riding  upon  the 
placental  mass ;  the  upper  segment  is  smaller  and  harder.  Some- 
times in  this  state  it  may  relax  and  fill  with  blood,  so  that  the 
outline  of  the  organ  may  not  be  palpable.  The  birth  of  the 
placenta  is  followed  by  increased  retraction  and  contraction  of 
the  uterus,  so  that  the  fundus  sinks,  the  largest  part  of  the  organ 
being  below  the  pelvic  brim. 

Duration  of  I^abor. — It  is  customary  to  regard  twenty-four 
hours  as  the  limit  for  normal  labors,  but  this  is  rather  long.  Spiegel- 
berg  found  in  506  cases  the  average  for  primiparae  to  be  17  hours 
and  for  multiparae  12  hours.  Hecker  found  it,  in  primiparae  over 
thirty,  21.1  hours;  Ahlfeld,  in  82  women  over  thirty-two,  27.6 
hours.  The  first  stage  is  the  longest,  but  it  is  very  difficult  in 
many  cases  to  estimate  its  duration,  because  dilatation  may  begin 
before  pains  are  felt  by  the  woman,  and  because  it  is  impossible 
to  determine  accurately  when  this  stage  is  completed.  In  multi- 
paras it  may  average  about  7I  hours.  The  second  stage  in  multi- 
parae lasts  about  i-^  hours.  The  third  stage  averages  from  10  to 
25  minutes. 


156      AA'ATOA/y  AND   PHYSIOLOGY   OF  NORMAL   LABOR. 


CHAPTER    II. 
ANATOMY  AND  PHYSIOLOGY  OF  NORMAL  LABOR, 

nRST  AND  SECOND  STAGES. 
THE  SOFT  PARTS. 

Form  and  Dimensions  of  the  Uterus. — During  the 
greater  part  of  the  first  stage  the  position  and  size  of  the  main 
portion  of  the  uterine  body  are  not  much  altered.     The  exami- 


FlG.  76. — Vertical  mesial  section  of  a  multipara,  who  died  of  tuberculosis  early  in 
the  first  stage  of  labor  at  full  time.  The  body  was  frozen  (Barbour  and  Webster)  :  a, 
Promontory;  b,  venous  sinuses;  c,  cervix;  d,  pouch  of  Douglas;  <?,  tip  of  coccyx;  f, 
rectum  ;  g,  liquor  amnii ;  h,  placenta;  /,  left  hand  ;  7,  symphysis  pubis  ;  k,  uterovesical 
reflection  of  peritoneum  ;  /,  bladder;  m,  urethral  orifice;  «,  vagina. 

nation  of  frozen  sections  reveals  variations  in  the  height  of  the 
fundus,  but  these  are  due  to  various  factors — /.  e.,  individual  dif- 
ferences in  the  size  of  the  uterus,  variations  in  the  inclination  of 
the  pubes,  the  position  in  which  the  body  is  frozen,  the  presence 


FIRST  AND   SECOND   STAGES. 


157 


or  absence  of  contraction  in  the  musculature.  The  influence  of 
primiparity  or  multiparity  is  also  of  some  importance.  In  Pesta- 
lozza's  first-stage  case,  a  sextipara,  the  fundus  was  opposite  the 
first  lumbar  vertebra,  being  1 1  in.  above  the  pubes  ;  in  Pinard 
and  Varnier's,  a  primipara,  it  was  opposite  the  junction  of  the 
first  and  second  lumbar  vertebrae,  9J  in.  above  the  pubes ;  in 
Tibone's,  a  bipara,  g\  in.  above  the  pubes ;  in  Schroeder's,  a 
quadripara,  in  which  the  uterus  lay  in  the  axis  of  the  brim,  8  in. 
above  the  pubes. 

These  figures  may  be  compared  with  measurements  made  in 


Extent  0}  separation  of  membrane) 


Retraction  riui 

utero-vesicat 
peritoneum 

Madder 


Mvx:o%L»  membrane 
of  cervix 


Post-erior  fofnix 


Fig.  jj. — Portion  of  vertical  mesial  section  of  Schroeder's  first  stage  of  labor  case. 
The  head  of  the  fetus  and  liquor  amnii  have  been  removed,  and  the  bag  of  membranes 
so  far  cut  away  as  to  show  their  line  of  attachment.  Note  the  dilatation  of  the  cervix, 
the  more  advanced  taking-up  of  its  posterior  wall,  the  thinning  of  the  lower  segment 
anteriorly  below  the  retraction  ring,  tlie  extent  of  separation  of  the  membranes,  and  the 
bladder  not  drawn  up  (from  Barbour's  Anatomy  of  Labor). 


full-time  cases.  In-  Braune's  and  Waldeyer's  cases,  both  multi- 
parae,  where  the  long  axis  of  the  uterus  lay  parallel  to  the  spinal 
column,  the  fundus  was  on  a  level  with  the  disk  between  the  first 
and  second  lumbar  vertebrae,  10  in.  above  the  pubes;  in  Braune 
and  Zweifel's  case,  a  primipara,  1 1  in.  above  it.  The  changes  in 
the  first  stage  do  not  appear,  therefore,  to  alter  the  position  of 
the  fundus.  It  is  undoubtedly  lowered  when  the  anterior  abdom- 
inal wall  is  very  lax,  so  that  the  uterus  can  fall  forward  when  the 
woman  stands  erect.  During  a  strong  pain  the  fundus  moves 
forward  and  sinks  somewhat,  the  body  becoming  more  globular 


158      ANATOMY  AND   PHYSIOLOGY   OF  NORMAL    LABOR. 


Fig.  78. — Transverse  section  of  body  of  uterus  in  the  first  stage  of  labor  (Barbour): 
a.  Spinal  column  of  fetus;  b,  fourth  lumbar  vertebra;  c,  left  ureter;  d,  uterus;  e,  left 
leg  of  fetus  ;  /  placenta  ;  g,  uterine  sinuses. 

than  in  the  intervals  between  the  pains ;  in  a  case  of  Barbour's,  a 
sextipara,  first  stage,  the  vertical  mesial  circumference  was  28  in., 


Fig.  79. — Transverse  section  of  body  of  uterus  in  the  second  stage  of  labor  (com- 
pare with  Fig.  78)  (Barbour  and  Webster)  :  a.  Right  broad  ligament;  b,  umbilical  cord  ; 
c,  index  finger ;  d,  sinus  of  wall ;  e,  wall  of  uterus ;  /,  fourth  lumbar  vertebra  ;  g,  left 
ureter;  h,  left  broad  ligament;  /,  spinal  column  of  fetus;  y,  liquor  amnii. 

the  widest  horizontal  24.2  in.,  the  coronal  26  in.    During  contrac- 
tion the  uterus  is  scarcely  moulded  by  the  spine  and  other  struct- 


FIRST  AND   SECOND   STAGES. 


159 


ures  ;  between  contractions  moulding  readily  occurs.  It  shows 
the  same  variations  in  position  as  are  found  in  pregnancy — /.  c,  it 
may  be  slightly  lateriverted  or  rotated. 

In  the  second  stage  the  shape  of  the  uterus  becomes  altered. 
Following  the- diminution  of  the  uterine  contents  (in  Barbour  and 
Webster's  second-stage  case  the  amount  of  liquor  amnii  in  the 
uterus  amounted  to  ipcu.  in.  ;in  their  eighth-month  pregnancy 
it  was  26  cu.  in.)  as  a  result  of  rupture  of  the  membranes,  the 
uterine  body  retracts  and  becomes  less  globular,  its  transverse 
diameter  in  particular  becoming  lessened  (I  refer  to  cephalic  and 


Fig.  80. — Second  stage  of  labor.  Reconstruction  from  frozen  sections.  Death 
probably  occurred  during  a  uterine  contraction.  The  case  is  abnormal  in  regard  to 
the  membranes.  They  are  unruptured  and  bulge  downward  as  a  bag  as  far  as  the 
vulva  (Braune). 


breech  presentations).  As  the  head  of  the  fetus  descends  toward 
the  perineum  the  fundus  does  not  sink,  as  might  be  expected,  but 
either  remains  stationary  or  rises.  In  Barbour  and  Webster's  case 
(the  only  normal  second-stage  specimen  yet  described)  the  head 
of  the  fetus  bulges  the  perineum  and  the  fundus  lies  9I  in. 
above  the  pubes,  or  opposite  the  first  lumbar  vertebra.  This  posi- 
tion of  the  fundus  is  explained  by  the  undoing  of  the  flexed  atti- 
tude of  the  child  during  the  progress  of  labor,  leading  to  its  elon- 
gation. 

In  Braune's  and  Chiari's  specimens,  in  which  the  second  stage 
is  not  at  all  as  far  advanced,  the  fundus  is  at  the  junction  of  the 


l6o      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL    LABOR. 

second  and  third  lumbar  vertebrae.  In  the  former  the  long  axis 
of  the  body  is  in  Hne  with  that  of  the  pelvic  brim ;  in  the  latter  it 
is  parallel  with  the  spinal  column.  The  globular  shape  of  the 
body  in  Braune's  case  suggests  strongly  that  death  occurred 
during  a  period  of  contraction.  In  both  of  these  specimens  there 
is  the  abnormality  of  unruptured  membranes,  a  condition  that 
necessarily  somewhat  interferes  ^vith  the  normal  change  in  the 
shape  of  the  uterus. 

During  the  second  stage,  in  a  period  of  contraction,  as  the  ute- 


FlG.  8i. — Vertical  mesial  section  of  a  woman  who  died  in  the  second  stage  of  labor. 
The  fetus  and  liquor  amnii  are  removed.  The  case  is  abnormal  as  regards  the  mem- 
branes that  were  unruptured  (see  Fig.  80)  (Chiari)  :  «,  Limit  of  separation  of  mem- 
branes;  b,  retraction  ring;  c,  uterovesical  peritoneum  ;  d,  bladder;  e,  os  externum  ;  f, 
symphysis  pubis;  g,  vulva;  h,  promontory  of  sacrum  ;  /,  rectum;  j,  pouch  of  Douglas. 


rine  body  hardens  and  moves  forward  the  fundus  temporarily  sinks 
somewhat,  rising  again  when  the  pain  has  passed.  Permanent 
descent  of  the  fundus  only  takes  place  when  the  head  begins  to 
escape  from  the  vulva.  As  the  fetus  is  born  the  uterine  body  re- 
tracts so  as  to  embrace  the  placenta,  as  is  shown  in   Pestalozza's 


specimens. 

Differentiation 


of  the  Wall  of  the  Uterus.— As  labor 


FIRST  AND   SECOND   STAGES. 


i6i 


proceeds  a  marked  differentiation  of  the  wall  of  the  uterus  above 
the  cervix  into  upper  and  lower  segments  is  gradually  brought 
about.  During  the  first  stage,  as  is  shown  by  frozen  sections, 
this  change  occurs  with  considerable  variability  in  different  cases. 
In  Barbour  and  Webster's  early  first-stage  case  the  anterior  part 
of  the  wall  for  2  in.  above  the  cervix  is  the  thinnest  portion ;  the 


-!/ 


Fig.  82. — Vertical  mesial  section  of  woman  who  died  in  the  second  stage  of  labor 
during  a  pain.  The  fetus  and  liquor  amnii  are  removed.  The  case  is  abnormal  as 
regards  the  membranes  which  were  unruptured  (see  Fig.  80)  (Braune) :  a.  Retraction 
ring;  b,  uterovesical  peritoneum;  c,  fundus  of  bladder;  d,  os  externum;  e,  vulva;/; 
promontory  of  sacrum  ;  g,  rectum;  h,  pouch  of  Douglas. 


corresponding  part  of  the  posterior  wall  is  somewhat  thicker,  being 
equal  to  the  thickness  of  that  part  of  the  wall  to  which  the  pla- 
centa is  attached. 

In  Winter's  early  case  the  wall  above  the   cervix,  in   front  and 
behind,  measures  4  mm.  in  thickness  for  a  short  distance,  gradually 
passing  into  the  thicker  wall  above.     In   Pestalozza's  early  case 
11 


1 62      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL   LABOR. 

the  wall  measures  2  mm.  above  the  cervix,  gradually  thickening 
above.  In  Schroeder's  more  advanced  first-stage  specimen  the 
anterior  wall  above  the  cervix  is  2  mm.  thick  for  a  distance  of  5.5 
cm.,  beyond  which  the  thickness  is  four  times  as  great ;  posteriorly 
it  is  2.8  mm.  for  a  distance  of  3.5  cm.,  then  becoming  5  mm.  thick. 


Fig.  83. — Vertical  mesial  section  of  a  primipara  who  fatally  poisoned  herself  in  the 
advanced  second  stage  of  labor.  The  body  was  frozen.  The  phenomena  of  labor 
were  normal  (Barbour  and  Webster):  a.  Retraction  ring;  b,  lower  uterine  segment; 
c,  promontory;  d,  os  externum  ;  e,  pouch  of  Douglas ;  /,  rectum  ;  g,  coccyx  ;  h,  liquor 
amnii ;  /,  placenta;/,  retraction  ring;  k,  lower  uterine  segment;  /,  bladder;  in,  os 
externum  ;  «,  symphysis  pubis  ;  o,  urethral  orifice  ;  /,  caput  succedaneum  ;  q,  perineum. 


In  this  case  the  transition  is  so  abrupt  as  to  have  been  termed  a 
"  contraction  ring"  by  Schroeder,  being  about  9.7  cm.  above  the 
OS  internum  in  front  and  9  cm.  behind.  In  the  other  cases  men- 
tioned no  such  ring  can  be  demonstrated. 

In  von  Saexinger's  first-stage  case,  in  which  labor  began  one 


FIRST  AND   SECOND   STAGES. 


163 


month  before  term,  the  wall  above  the  cervix  is  thinner  than  the 
part  higher  up,  the  posterior  being  slightly  thicker  than  the  an- 
terior. There  is  a  gradual  transition  between  the  upper  and  lower 
segments.  In  Winter's  first-stage  eighth-month  case  a  somewhat 
similar  condition  was  found.  In  Lusk's  eighth-month  case  the 
transition  between  the  upper  and  lower  segments  was  marked  by 


Fig.  84. — Cervix  compressed  between  head  and  pelvic  floor  at  beginning  of  labor 
in  a  sextipara.  (One-third  natural  size.)  (Barbour.)  The  cervix  extends  from  the 
tuberosity  up  to  the  right-hand  a  ;  the  vagina  is  shown,  and  also  the  ureter  and  the 
base  of  the  broad  ligament ;  the  area  on  the  side  not  covered  with  peritoneum  being 
the  shaded  space  (a,  a,  a). 

a  ridge  (in  this  case  there  was  probably  premature  escape  of  the 
waters). 

The  most  marked  differentiation  between  the  upper  and  lower 
segments  becomes  evident  in  normal  cases  during  the  second 
.stage,  and  is  marked  by  a  sudden  transition  in  the  thickness  of  the 
wall.     The  upper  segment,  while  varying  in  thickness,  is  generally 


164      A.VA7VJ/V  A.YD   PHYSIOLOGY  OF  NORMAL    LABOR. 

much  thicker  than  the  lower  segment,  which  may  also  vary.  The 
lower  edge  of  the  upper  segment  usually  projects  as  a  ridge,  which 
has  been  variously  denominated.  This  ridge  varies  somewhat  in 
thickness,  contour,  and  position  in  different  cases.  It  is  generally 
termed  "  contraction  ring  "  or  "  retraction  ring.  "  In  Braune's 
second-stage  case  it  is  4.2  in.  from  the  os  externum  and  6.6  in. 
from  the  fundus  ;  in  Chiari's  2.2  in.  from  the  os  externum  and  J."] 
in.  from  the  fundus.  This  difference  is  probably  due  to  the  fact 
that  in  the  former  the  upper  uterine  segment  is  contracting  and 
pulHng  on  the  lower  segment,  while  the  head  is  high,  stretching 
it ;  while  in  Chiari's  the  latter  has  descended  low  in  the  pelvis.  In 
Barbour  and  Webster's  second-stage  case  the  ridge  is  v&xy  dis- 
tinctly marked  ;  above  it  the  thickness  of  the  upper  segment 
varies,  being  greatest  posteriorly  (l  in.),  less  at  the  fundus  {^-^ 
in.),  and  least  where  the  placenta  is  attached  (1  in.).  The  lower 
segment  averages  ^  in.  in  thickness.  The  distance  from  the 
OS  externum  to  the  retraction  ring  is  2\  in.  anteriorly  and  3^  in. 
posteriorly,  following  the  cur\"ature  of  the  wall.  This  difference 
is  due  to  greater  stretching  of  the  lower  segment  behind  than  in 
front,  and  also  to  a  similar  variation  in  the  stretching  and  thinning 
of  the  cervix.  The  inner  surface  of  the  segment  below  the  mem- 
branes, which  were  somewhat  separated,  has  a  raw  appearance. 

Cervix  in  I/abor. — Ordinarily  the  canalization  of  the  cervix 
takes  place  from  above  downward.  In  primiparae  especially  it  can 
generally  be  made  out  that  the  lowest  portion  in  the  region  of  the 
OS  externum  is  the  last  to  begin  to  dilate.  The  sections  show  that 
the  cervix  is  unequally  thinned,  the  posterior  lip  being  usually 
elongated  more  rapidly  than  the  anterior.  In  the  most  extreme 
degree  of  dilatation  the  cervical  canal  has  a  diameter  of  four  or  more 
inches ;  its  wall  has  about  the  same  thickness  as  the  lower  uterine 
segment,  from  which  it  cannot  be  distinguished  by  the  naked  eye, 
as  the  prominence  of  the  wall  at  the  internal  os  is  entirely  obliter- 
ated. The  region  of  the  os  externum  is  easily  recognized  by  the 
persistence  of  the  fornix  vaginae  as  a  narrow  slit.  In  Barbour  and 
Webster's  case  the  latter  was  ^  in.  deep;  the  vaginal  portion  of 
the  cervix  was  scarcely  \  in.  thick,  but  it  was  of  sufficiently  firm 
consistence  to  cause  a  furrow  on  the  head  of  the  fetus.  The  inner 
surface  of  the  dilated  cervix  was  rough  and  shaggy. 

The  delimitation  of  the  level  of  the  os  internum  in  the  second  stage  of 
labor  has  been  a  much  disputed  question.  Braune,  in  his  case  pubhshed 
in  1872,  figured  it  at  the  level  of  the  retraction  ring.  He  acknowledged 
afterward  that  this  was  done  without  any  microscopic  examination  of  the 
tissues.  He  was  evidently  in  error,  placing  it  too  high.  Bandl,  in  his 
paper  in  1876  deahng  with  rupture  of  the  uterus,  also  wrongly  thought  that 
the  lower  uterine  segment  was  the  thinned  upper  part  of  the  cervix,  the 
level  of  the  os  internum  being  the  ridge  afterward  known  as  "  Bandl' s 
ring."  Chiari  published  his  case  in  1878,  and  from  microscopic  examina- 
tion of  the  wall  fixed  the  upper  limit  of  the  cervix  above  the  os  externum, 


FIRST  AND   SECOND   STAGES. 


165 


1.2  in.  anteriorly  and  i  in.  posteriorly.  Barbour  and  Webster  have  made 
a  very  careful  microscopic  study  of  the  walls  in  their  case,  and  have  shown 
that  the  cervix  does  not  reach  as  high  as  the  retraction  ring,  but  is  sepa- 
rated by  a  thin   segment  derived  from  the  supracervical  portion  of  the 


Fig.  85. — Vertical  mesial  section  of  Barbour  and  Webster's  second  stage  of  labor 
case.  The  fetus  and  liquor  amnii  have  been  removed  :  vi.  Amniotic  surface  ;  the  mem- 
branes are  attached  as  far  down  as  the  wavy  line  x,  between  the  os  internum  {oi)  and 
the  retraction  ring  {rr)  ;  p,  placenta ;  sp,  promontory  of  sacrum  ;  uvp,  uterovesical 
pouch  of  peritoneum  ;  ppd,  poucli  of  Douglas;  nf,  ridge  corresponding  to  neck  of 
fetus;  c^,  OS  externum  ;  1^,  bladder-wall  compressed  behind  pubes ;  ?/,  urethra;  av,pv, 
anterior  and  posterior  vaginal  walls  ;  r,  rectum  ;  a,  stretched  anus  ;  pb,  stretched  peri- 
neum. 


uterine  wall.  In  their  specimen  the  membranes  were  firmly  attached  as 
low  as  the  retraction  ring,  below  which  they  were  separated.  Below  the 
separated  edge  fragments  of  membranes  were  attached  in  places  to  the 
wail.      Still   lower,  remnants   of  cervical  glands  could  be  traced  as  far  as 


1 66      AA^TOJIIV  AND  PHYSIOLOGY  OF  NORMAL   LABOR. 

the  OS  externum.  Between  the  remnants  of  membranes  and  those  of  cervi- 
cal glands  lay  the  region  of  the  os  mtcmtcvi — about  l.J  in.  above  the  os 
externum  anteriorly  and  1.3  in.  posteriorly.    Owing  to  stretching,  bruising, 


Fig.  86. — Barbour  and  Webster's  second  stage  of  labor  case.  Reconstruction  from 
frozen  sections.  In  this  case  labor  is  farther  advanced  than  in  Braune's  and  Chiari's 
specimens  (Figs.  80,  90)  and  the  membranes  have  ruptured.  The  flexion  of  the  head 
on  the  chest  is  less  than  in  pregnancy.  (See  Fig.  112.)  The  head  is  at  the  vulva.  It  is 
not  completely  rotated.  The  body  of  the  fetus  has  not  rotated,  the  back  being  toward 
the  mother's  left  side  (from  Barbour's  Atlas  of  the  Anatotny  of  Labo?-) :  p,  Placenta; 
rr,  retraction  ring ;  ps,  sacral  promontory ;  uvp,  uterovesical  reflection  of  peritoneum  ; 
d,  bladder ;  u,  urethra ;  oe,  os  externum ;  avw,  anterior  wall  of  vagina ;  pv,  posterior 
vaginal  wall;  cs,  caput  succedaneum ;  v,  vulva;  a,  stretched  anus;  pb,  stretched  peri- 
neum. 


and  laceration  the  surface  epithelium  was  considerably  destroyed  and  the 
glands  much  separated  ;  it  was,  therefore,  impossible  to  trace  the  expanded 
OS  internum  with  absolute  accuracy  as  a  definite  line.  It  could  only  be 
approximately  placed. 


FIRST  AND   SECOND   STAGES. 


167 


Zweifel,  in  his  recent  study  of  a  case  of  placenta  prtevia,  in  which 
turning  had  been  carried  out,  wrongly  describes  the  cervix  as  being  elon- 
gated to  3.8  in.  in  front  and  3  in.  posteriorly,  fixing  the  upper  limit  at  the 
retraction  ring.  He  claimed  that  Braune  was  right  in  his  original  statement. 
It  is  interesting  to  note  that  Leopold,  in  a  very  similar  case,  describes  the 
length  of  the  cervix  as  i  in. 

Bladder. 


Kectutn. 
Fig.   87. — Cervix  of  five  and  a  half  months'  primipara  in  dilatation  period,  with 
marked  irregularity  in  progress  of  dilatation  of  posterior  and  anterior  lips,  the  poste- 
rior being  nearly  flattened  (Winter;  frozen  section,  five-eighths  natural  size). 


The  great  mass  of  anatomic  evidence  undoubtedly  goes  to 
show  that  during  labor  the  vertical  measurement  of  the  cervix  is 
normally  lengthened  not  more  than  about  half  an  inch.  The  wall 
of  the  cervix  and  lower  segment,  while  enormously  stretched  and 


Fig.   88. — Dilating  cervix  of  eighth-month  primipara,  with   pronounced  thinning  of 
posterior  lip  (Winter  ;  frozen  section,  two-thirds  natural  size). 

thinned  in  the  second  stage  of  labor,  does  not  entirely  lose  its 
power  of  altering  its  shape  by  retraction,  for  Barbour  and  Web- 
ster's .specimen  shows  thickenings  corresponding  to  depressions 
on  the  fetus. 


l68      AXATOiMY  AA'D   PHYSIOLOGY  OF  NORMAL    LABOR. 

During  the  first  stage,  though  the  cervix  is  thinned  and  dilated, 
so  that  the  os  internum  is  moved  away  from  the  os  externum,  it 
does  not  become  elevated  in  the  pelvis  until  dilatation  is  well 
advanced.  In  the  second  stage  both  the  os  externum  and  the  os 
internum  are  higher  than  at  the  beginning  of  labor,  the  elevation 
of  the  former  being  much  more  marked  anteriorly  than  poste- 
riorly. In  Braune's  case  the  distance  of  the  os  externum  below 
the  brim  anteriorly  measured  i|  in.,  and  posteriorly  3|^  in.;  in 
Chiari's,  i  in.  in  front,  2\  in.  behind ;  in  Barbour  and  Webster's, 


Fig.  89. — Cast  of  uterine  cavity  and  vagma  after  removal  of  fetus  and  liquor  amnii 
in  the  advanced  second  stage  of  labor  (Barbour  and  Webster)  :  A,  Anterior  surface 
B,  left  lateral  surface,   mp.  Mesial  plane  of  body,  corresponding  to  section  in  Fig.  83 
F,  fundus  uteri ;  rff.  Iff,  right  and  left  inner  ends  of  Fallopian  tubes  ;  P,  placental  area 
rr,  furrow  caused  bv  retraction  ridge  ;  nf,  furrow  corresponding  to  depression  of  neck 
of  fetus ;  oe,  os  externum  ;    V,  vagina  ;  v,  vulva. 


i^  in.  in  front,  i|  in.  behind.  The  lower  level  occupied  by  the 
posterior  lip  of  the  cervix  is  due  to  the  greater  thinning  and 
stretching  of  the  cervix  and  lower  uterine  segment  posteriorly. 

Vagina. — The  softened  vaginal  wall  becomes  stretched  from 
above  downward  as  labor  progresses.  The  process  begins  in  the 
first  stage,  when  the  bag  of  waters  is  forced  downward  during  the 
dilatation  of  the  cervix.  After  the  waters  escape  the  head  of  the 
fetus  acts  directly  on  the  vaginal  walls.  In  an  advanced  second- 
stage  case — /.  e.,  Barbour  and  Webster's,  the  dilatation  is  so  great 
that  the  distance  of  the  anterior  from  the  posterior  wall  in  the 


FIRST  AND   SECOND   STAGES.  1 69 

pelvic  cavity  reaches  4  in. ;  the  wall  becomes  greatly  thinned, 
especially  posteriorly.  In  Barbour  and  Webster's  case  its  thick- 
ness measured  only  4^  in. 

The  posterior  wall  becomes  stretched  in  a  vertical  direction, 
the  anterior  wall  being  scarcely  affected  in  this  way.  This  is 
most  evident  when  the  head  is  low  down,  bulging  the  perineum. 
Thus,  in  Barbour  and  Webster's  case  the  length  of  the  posterior 
wall  from  vulva  to  os  externum  measured  7  in.,  the  anterior  wall 
being  only  2  in.  In  this  specimen  a  considerable  proportion  of 
the  elongation  belongs  to  that  part  of  the  wall  in  relation  to  the 
perineum,  which  is  much  thinned  and  stretched  from  above  down- 
ward.    In  Braune's  specimen,  where  the  head  is  not  so  low,  the 


Uterovesical  peritotieujH. 

Os  int.    1 

>■  Cervical  canal. 
Os  e-xt.  J 

Bladder. 

Syjtiphysis. 

Bag  of  membranes. 


Fig.  90. — Advanced  second  stage  of  labor.  Reconstruction  from  frozen  sections. 
The  case  is  abnormal  as  regards  the  membranes.  They  are  unruptured  and  bulge 
slightly  below  the  head  (Chiari). 

posterior  wall  measures  5.5  in.  in  length  and  the  anterior  2.2  in. 
In  Chiari's,  where  the  head  has  reached  the  sacral  segment  of 
the  pelvic  floor  but  has  not  begun  to  bulge  it,  the  posterior  wall 
measures  5  in.  and  the  anterior  2.3  in. 

Pelvic  Floor  Projection. — In  the  first  stage  there  is  no 
change  ;  in  the  second  stage  there  is  a  slight  increase  until  the 
head  is  actually  being  born,  when  it  becomes  greater.  The 
increase  before  this  act  is  much  less  than  is  generally  taught,  the 
explanation  being  the  driving  downward  and  backward  of  the 
coccyx  and  the  elevation  of  the  pubic  segment  of  the  floor.     If 


I/O      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL   LABOR. 


the  bag  of  membranes  persists  in  the  second  stage,  there  may  be 
some  premature  bulging  of  the  floor.  The  skin  distance  from 
_  coccyx   to   symphysis    increases   as 

""  ~~  the  sacral  segment  is  pushed  down- 

ward. 

Bladder  and  Urethra. — The 
urethral  orifice  normally  during  la- 
bor moves  posterior  to  the  plane 
occupied  by  it  during  pregnancy 
and  is  slightly  elevated.  A  long- 
persisting  bag  of  membranes  inter- 
feres with  this  change.  The  junc- 
tion of  the  urethra  and  bladder  in 
the  early  part  of  the  first  stage  is 
scarcely  moved  from  the  position 
occupied  by  it  during  pregnancy, 
but  toward  the  latter  part  and  in  the 
second  stage  is  somewhat  elevated. 
In  pregnancy  it  is  placed  between  2\ 
and  3  in.  below  the  brim.  In  the 
advanced  second  stage  (Barbour  and 
Webster)  it  lies  i|^  in.  below. 

The  bladder  itself  is  variously  dis- 
posed in  the  different  sections.  It 
has  been  noted  that  in  pregnancy, 
in  the  empty  condition,  it  is  almost 
always  found  entirely  within  the  true 
pelvis,  only  occasionally  a  small  por- 
tion rising  above  the  symphysis.  In 
the  first  stage  of  labor  the  same  posi- 
tion is  found.  In  the  second  stage, 
while  the  main  portion  lies  below  the 
brim,  a  small  portion  is  usually  found 
above. 

In  Barbour  and  Webster's  second- 
stage  case  a  small  pyramidal  portion 
of  the  bladder  reached  i^  in.  above 
the  brim  ;  the  lowest  level  was  f  in. 
above  the  lower  edge  of  the  sym- 
physis ;  its  transverse  measurement, 
as  it  lay  compressed  against  the  pu- 
bes,  was  4f  in. 


Fig.  91. — Cast  of  fetus  removed 
while  frozen  from  case  of  primipara 
who  died  in  advanced  second  stage 
of  labor  (Barbour  and  Webster) :  a. 
Slight  furrow  caused  by  cervix  at  os 
externum  ;  b,  caput  succedaneum  at 
vulvar  orifice  ;  c,  groove  caused  by 
retraction  ridge.  The  dotted  area 
on  the  head  indicates  the  position  of 
the  anterior  fontanel.  The  length 
of  the  fetus  from  vertex  to  breech  is 
13  in. ;  the  flexion  of  the  body  and 
of  the  head  on  the  chest  being  less 
than  in  pregnancy.  The  head  is 
partly  rotated. 


Analysis  of  Movements  in  the  Pel= 

vie  Floor  during  Labor. — The  changes 

in  the  pelvic  floor  during  labor  have  given  rise  to  differences  of  opinion. 

A  study  of  the  abundant  anatomic  sections  at  our  disposal  should  settle  all 

important  matters  in  dispute. 


FIRST  AND   SECOND   STAGES.  I/I 

With  regard  to  the  pubic  segment,  it  might  be  supposed  (as  has  been 
described  by  some)  that,  as  a  result  of  the  forcing  down  of  the  uterine  con- 
tents by  labor  pains,  it  would  be  made  to  descend.  This  certainly  would 
be  the  case  were  there  no  restraining  force  at  work  from  an  early  stage  of 
labor — viz. ,  the  upward  traction  exercised  by  the  retracting  and  contracting 
upper  uterine  segment  on  the  lower  segment  and  cervix  through  the  attach- 
ment of  the  latter  to  the  bladder  and  vagina.  This  upward  traction  is,  how- 
ever, from  the  first  also  counteracted  by  the  thinning  of  the  lower  uterine 
segment  and  cervix,  so  that  it  barely  serves  during  the  early  part  of  the 
first  stage  to  keep  the  pubic  segment  in  its  preparturient  position. 

There  are  three  factors  in  operation  : 

1.  The  upward  traction  caused  by  the  retracting  and  contracting  upper 
uterine  segment. 

2.  The  downward  pressure  of  the  uterine  contents. 

3.  The  thinning  of  the  lower  uterine  segment  and  cervix. 

For  a  time  in  the  first  stage  these  factors  are  so  balanced  that  the  pubic 
segment  is  scarcely  altered.  With  the  advance  of  this  stage  the  upward 
traction  of  the  uterus  becomes  stronger  and  the  downward  pressure  of  the 
uterine  contents  on  the  pubic  segment  weaker,  and  gradual  elevation  of  ihe 
segment  takes  place. 

As  we  follow  its  movement  during  the  second  stage  its  elevation  contin- 
ues, because  sections  show  : 

1.  That  the  junction  of  the  urethra  and  bladder  is  then  higher  in  the 
pelvis. 

2.  That  the  urethral  orifice  is  higher. 

3.  That  the  thickness  of  the  tissue  between  the  lower  margin  of  the 
pubes  and  vagina  is  diminished. 

4.  That  the  os  externum  is  higher  anteriorly. 

Though  for  a  time  in  the  early  part  of  the  first  stage  there  is 
no  actual  elevation  of  the  pubic  segment,  the  uterovesical  pouch 
of  peritoneum  tends  to  be  raised  as  the  result  of  stripping  of  the 
peritoneum  from  the  posterior  part  of  the  upper  surface  of  the 
bladder,  due  to  upward  traction  of  the  uterus. 

Whereas  in  late  pregnancy  the  os  internum  and  the  utero- 
vesical pouch  are  the  same  distance  below  the  brim,  in  the  first- 
stage  sections  the  latter  is  at  a  higher  level.  This  difTerence  must 
be  accounted  for  by  the  fact  that  the  thinning  and  elongation  of 
the  lower  uterine  segment  are  chiefly  marked  just  above  the 
cervix.  In  the  second  stage  the  uterovesical  pouch  is  raised 
above  the  brim  (it  may  be  as  much  as  one  inch). 

The  pouch  of  Douglas  is  not  materially  altered  during  labor. 
In  Barbour  and  Webster's  second-stage  case  the  uterosacral  liga- 
ments extended  from  the  uterus  about  an  inch  above  the  os 
externum,  backward  and  slightly  downward  to  the  sacrum. 
Laterally  the  pelvic  peritoneum  is  somewhat  raised,  especially 
anteriorly.  The  broad  ligaments  are  compressed  between  the 
uterus  and  surrounding  structures. 

As  labor  advances,  the  upward  traction  of  the  uterus  becoming 
stronger,  the  cervix  is  gradually  elevated,  and  with  it  that  part  of 
the  bladder  attached  to  it.     Then  the  upper  posterior  part  of  the 


1/2      A.V.4T0MY  AiVn   PHYSIOLOGY  OF  NORMAL    LABOR. 

bladder  is  made  to  slide  upward  and  forward,  and  the  base  in  its 
turn,  with  the  rest  of  the  posterior  part  of  the  pubic  segment, 
moves  in  the  same  direction.  This  process  goes  on  until  the 
bladder  lies  behind  and  partly  above  the  pubes,  its  cavity  then 
appearing  on  vertical  mesial  section  as  a  slit  directly  continuous 
with  the  urethra,  parallel  to  the  pubes  and  to  the  cervix,  which 
lies  close  behind  it.  The  pubic  segment  might,  therefore,  be  de- 
scribed as  moving  in  the  arc  of  a  circle  whose  center  is  the  attach- 
ment to  the  lower  part  of  the  pubes  of  the  anterior  true  ligaments 
of  the  bladder  (anterior  visceral  layer  of  the  pelvic  fascia) ;  the 
lower  and  anterior  portion  of  the  segment  is  very  little  raised,  the 
posterior  part  to  a  considerable  extent. 

Accompanying  the  uterine  traction  are  two  other  factors  that 
help  to  move  the  pubic  segment  upward  and  forward — viz.,  the 
stiffening  and  forward  movement  of  the  uterine  wall  during  the 
pains,  and  the  compression  by  the  head  after  it  has  descended 
through  the  dilated  cervix  into  the  pelvic  cavity.  As  the  latter 
advances  the  resistance  of  the  sacral  segment  tends  to  press  it 
still  more  strongly  against  the  pubes. 

As  has  already  been  pointed  out,  only  a  small  part  of  the 
bladder  rises  above  the  brim.  In  Braune's  second-stage  case  its 
highest  point  is  |  in.  above  ;  in  Chiari's  i  in. ;  and  in  Barbour  and 
Webster's  i^  in.  In  the  latter  labor  is  further  advanced  than  in 
the  other  cases,  in  which  it  is  to  be  noted  that  the  bag  of  mem- 
branes is  unusually  persistent.  It  is  probable  that  such  a  con- 
dition of  the  membranes  interferes  somewhat  with  the  normal 
elevation  of  the  pubic  segment.  It  does  not  appear  that  the 
urethra  is  at  all  elongated  during  labor.  Hart  has  shown  that 
it  becomes  somewhat  dilated  as  a  result  of  stretching  of  the 
vaginal  wall  during  the  second  stage. 

Tissues  Outside  of  the  Genital  Passage. — As  the  fetus 
descends  into  the  pelvic  cavity  the  paracervical  and  paravaginal 
tissues  are  greatly  stretched  and  pressed  toward  the  bony  walls. 
In  Barbour  and  Webster's  case  the  posterior  vaginal  wall  is  \  in. 
from  the  middle  of  the  sacrum  and  f  in.  from  its  lower  end. 

Although  the  vagina  and  cervix  are  greatly  thinned  in  ad- 
vanced labor,  the  risk  of  laceration  in  them  is  greatly  lessened 
by  the  elastic  support  given  them  by  the  tissues  packed  between 
them  and  the  pelvic  wall. 

Hart  has  pointed  out  that  (apart  from  the  perineal  region)  the 
upper  part  of  the  posterior  vaginal  wall  is  the  weakest  and  most 
apt  to  be  torn  in  labor.  It  ruptures  less  frequently  than  the 
cervix  and  lower  uterine  segment.  The  compression  of  the 
empty  rectum  shows  how  any  distention  of  it  will  interfere  with 
the  roominess  of  the  pelvic  cavity. 

In  the  advanced  second  stage  the  tissues  of  the  sacral  segment 
are  driven  downward,  the  coccyx  being  bent  backward,  the  anus 


FIRST  AND   SECOND   STAGES. 


^/j 


and  perineal  body  being  pushed  downward  and  forward  as  the 
head  advances  toward  the  outlet.  As  Hart  has  pointed  out,  that 
part  of  the  sacral  segment  in  front  and  inclusive  of  the  anterior 
rectal  wall  is  elongated  and  driven  forward  more  markedly  than 
the  postanal  portion,  the  anus  being  opened  up  so  as  usually  to 
assume  a  D-shape,  the  straight  side  being  anterior.  In  a  number 
of  measurements  Hart  found  the  average  anteroposterior  diameter 
to  be  about  i  in.,  the  greatest  transverse  being  about  ly^y  in.  The 
former  diameter  is  greatest  while  the  head  first  bulges  the  peri- 
neum ;  the  latter  when  it  is  passing.  There  are  occasional  devia- 
tions from  the  above-described  shape. 

The  modification  of  the  bony  canal  by  the  soft  structures  has 


Frontal  suture 


Right  fiarietal 


Right  rajitus  of 
piibes. 


Lovjer   part    of 

sacrum. 
Rectum. 


Vaginal  wall. 


Left  parietal 


Fig.  92. — Transverse  section  of  the  pelvis  in  the  second  stage  of  labor.  Note  the 
somewhat  oval  shape  of  the  genital  canal  and  the  moulding  of  the  head  (Barbour  and 
Webster). 

been  well  demonstrated  by  frozen  sections.  At  the  brim  the 
transverse  diameter  is  shortened  by  the  psoasiliacus  muscles. 
When  the  thighs  are  extended  and  the  muscles  tense  they  inter- 
fere with  the  brim  .space  more  than  when  the  thighs  are  flexed 
and  the  muscles  relaxed.  The  blood-vessels  that  cross  the  brim 
exercise  a  very  slight  influence  in  shortening  the  diameters. 
When  the  fetus  is  very  large  or  the  bony  pelvis  undersized  the 
pressure  upon  them  may  be  very  marked. 

The  rectum  usually  crosses  the  brim  on  the  left  side,  and  so 
causes  a  shortening  of  the  left  oblique  diameter.  Frequently  a 
fold  of  the  sigmoid  flexure  may  descend  into  the  pelvis,  helping 
further  to  interfere  with  its  roominess.  The  bladder  compressed 
behind  the  pubes  causes  a  shortening  of  the  conjugate.  In  the 
second  stage  of  labor  the  brim  diameters  are  further  diminished  by 
the  thickness  of  the  uterine  wall.  The  exact  amount  of  interfer- 
ence caused  by  the  soft  tissues  cannot  be  definitely  stated.     They 


1/4      AXATOMY  AND   PHYSIOLOGY  OF  NORMAL    LABOR. 

are  capable  of  compression,  and  variations  occur.  From  a  study 
of  frozen  sections  it  seems  that  the  conjugate  of  the  brim  is  ordi- 
narily lessened  about  half  an  inch. 

The  bony  cavity  is  diminished  by  a  variety  of  structures.  The 
rectum,  below  the  brim,  may  be  on  the  left  side,  but  often  may 
cross  to  the  right  before  descending.  The  compressed  bladder 
shortens  the  conjugate.  The  walls  of  the  cervix  and  bladder  and 
the  loose  connecti\e  tissue  connected  with  them  shorten  all  the 
diameters.  The  pyriformis,  obturator  internus,  and  levator  ani 
muscles  interfere  with  the  roominess  of  the  cavity,  especially 
laterally.  This  interference  is  increased  by  the  resistance  of  the 
visceral  layers  of  the  pelvic  fascia  to  the  advancing  fetus. 

Barbour  and  Webster's  section  of  the  pelvis  during  the  second 
stage  shows  how  marked!}'  the  bony  cavity  is  altered,  so  that  the 
shape  of  the  genital  passage  on  transverse  section  is  oval,  the  long 
diameter  being  anteroposterior,  and  even  this  is  shorter  than  the 
corresponding  bony  conjugate  by  f  inch. 

PHYSIOLOGY. 

Causes  of  the  Onset  of  Normal  I^abor. — The  determining 
cause  of  the  commencement  of  labor  is  not  known.  The  following 
views  have  been  ad\"anced  : 

1.  Increasing  irritability  of  the  uterus,  the  normal  contractions 
that  occur  during  pregnancy  becoming  more  pronounced. 

2.  Stimulation  of  the  ner\e  centers  related  to  the  uterus. 
Brown-Sequard  believed  that  this  was  due  to  increased  COo  in 
the  blood.     Others  think  that  it  is  caused  by  chemical  substances. 

3.  Changes  in  the  decidua,  especially  diminution  in  the  caliber 
of  the  maternal  vessels  by  thickening  of  their  walls,  thrombosis, 
or  the  constriction  of  surrounding  connective  tissue. 

4.  Increasing  tension  on  the  uterine  wall. 

5.  Diminished  resistance  in  the  lower  part  of  the  uterus  owing 
to  softening  of  the  cervix. 

6.  Increased  movements  of  an  enlarged  fetus. 

7.  Habit  and  heredit}-. 

8.  Menstrual  periodicity.  T\-ler  Smith  advanced  the  view  that 
pregnancy  was  normalh-  interrupted  at  the  time  corresponding  to 
the  tenth  menstrual  epoch. 

9.  Exciting  causes — /.  r.,  exercise,  emotion,  etc. 

These  views  are  entirely  speculative.  Several  factors  may  be 
concerned.  The  uterus  is  probably  more  irritable  toward  the  end 
of  pregnancy  owing  to  its  increasing  size,  the  weight  of  the  fetus, 
the  influence  of  substances  circulating  in  the  blood  acting  on 
central  and  peripheral  nen^e  structures  and  even  on  the  uterine 
musculature  ;  the  quantity  of  CO..  in  the  blood  is  probably  in- 
creased.    There  are  well-marked  changes  in   many  of  the  vessels 


PHYSIOLOGY.  175 

of  the  decidua,  the  flow  of  blood  through  them  being  more  or  less 
altered.  The  cervix  usually  becomes  very  soft  and  dilatable. 
Whether  the  influence  of  the  tenth  missed  menstrual  period  is 
important  is  uncertain.  Tyler  Smith  believed  that  the  supposed 
pelvic  congestion  and  general  disturbance  played  a  part  in  de- 
termining the  onset  of  labor  at  this  time.  Certainly  in  early 
pregnancy  we  know  that  abortion  frequently  occurs  at  the  time 
corresponding  to  a  menstrual  epoch. 

The  Uterus  during  Labor. — Historic. — Until  the  middle  of  the  seven- 
teenth century  the  uterus  was  beheved  to  be  inactive  during  labor,  the  fetus 
being-  thought  to  deliver  itself  by  its  own  efforts.  It  was  Harvey  who  first 
described  uterine  contractions,  having  noticed  them  in  a  parturient  bitch. 
In  1857  Calliburces  removed  the  uterus  of  a  parturient  animal  and  observed 
that  uterine  activity  continued  so  as  to  expel  the  fetus. 

Spiegelberg,  in  1858,  experimented  on  the  uterus  in  situ  and  found  that 
compression  of  the  aorta  caused  uterine  contractions. 

Kehrer,  in  1863,  studied  artificial  production  of  peristaltic  movements 
by  heat.  Korner,  in  1864,  noted  movements  when  all  nerves  leading  to  it 
were  divided  and  when  the  uterus  was  irritated.  Reimann,  in  1869,  noticed 
that  an  excised  uterus  placed  in  a  chamber  at  blood  temperature  under- 
went rhythmic  peristalsis,  which  was  checked  by  a  rise  or  fall  of  temper- 
ature. 

Schlesinger,  in  1874,  after  division  of  the  cervical  spinal  cord  of  a 
bitch,  noticed  that  stimulation  of  the  sciatic  nerve  produced  uterine  con- 
tractions. 

Runge,  in  1878,  experimented  on  the  uterus  in  situ  on  the  living  animal, 
testing  the  reaction  to  hot  and  cold  water. 

Rein,  in  1880,  published  a  series  of  observations  to  the  effect  that  the 
severance  of  the  uterus  from  its  cerebrospinal  or  sympathetic  nerve  con- 
nections does  not  interfere  with  conception,  pregnancy,  or  labor.  He 
stated  that  the  cervical  ganglia  were  of  no  importance  as  automatic  uterine 
centers. 

Frommel,  in  1882,  first  registered  uterine  movements  graphically.  He 
described  spontaneous  rhythmic  contractions  in  the  virginal,  pregnant,  par- 
turient, and  puerperal  uterus  of  the  rabbit,  and  confirmed  Rein's  statement 
that  the  movements  are  independent  of  an  extra-uterine  center. 

Jacob,  in  1884,  confirmed  and  enlarged  upon  Frommel' s  observations. 
He  found  that  rapid  loss  of  blood  abolishes  uterine  contractions  ;  that  large 
doses  of  curara,  morphia,  and  chloral  slowed  contractions,  chloral  also 
diminishing  their  intensity  ;  strychnin  strengthening  contractions.  A  uterus 
separated  from  the  body  under  favorable  conditions  retains  for  a  long  time 
the  power  of  contracting.  Intermittent  electric  stimulation  strengthens 
contraction  and  causes  new  ones  ;  strong  interrupted  currents  interfere  with 
them.  Electric  stimulation  of  the  medulla  has  no  perceptible  influence  on 
them  in  normal  conditions  ;  after  division  of  the  cord  at  the  first  dorsal 
vertebra,  or  between  the  first  and  second  cervical  vertebrae,  electric  stimu- 
lation of  the  medulla  inhibits  contractions.  Electric  stimulation  of  the 
spinal  cord  after  separation  from  the  medulla  strengthens  contractions  or 
starts  new  ones  ;  stimulation  of  the  lumbar  region  is  most  effective.  Elec- 
tric stimulation  of  the  central  end  of  the  divided  sciatic  nerves  when  the 
medulla  and  spinal  cord  are  intact  has  no  particular  effect  on  uterine  con- 
tractions ;  if  the  medulla  be  separated  from  the  cord  such  stimulation 
strengthens   contractions.      Jacob  clearly  proved  that  an  excitory  center  for 


1/6    ajvatoa/v  and  physiology  of  normal  labor. 

uterine  movements  exists  in  the  lumbar  cord,  an  inhibitory  center  in  the 
medulla  oblongata.  His  experiments  also  show  that  the  rabbit's  uterus  is 
influenced  by  induced  electricity  differently  from  the  lymph  heart  and  blood 
heart  of  frogs,  which  are  of  striped  muscle,  acting  rhythmically. 

Goltz  divided  the  spinal  cord  of  a  bitch  at  the  first  lumbar  vertebra. 
Later  she  went  into  heat,  became  pregnant,  and  gave  birth  to  two  pups,  one 
of  which  was  dead  ;  the  other  she  suckled. 

Helme,  in  1891,  carried  out  a  series  of  experiments  on  the  virginal, 
pregnant,  and  puerperal  uterus  of  the  sheep,  and  observed  that  in  all  these 
conditions  it  exhibited  regular  and  rhythmical  contractions,  which  continued 
after  removal  from  the  body  if  artificial  circulation  were  kept  up  ;  the 
movements  being,  therefore,  independent  of  all  extra-uterine  nerve  centers. 
He  proved  that  they  are  not  due  to  any  rhythmic  contraction  and  relaxation 
of  the  vessel  walls,  but  either  to  an  inherent  rhythmic  function  of  the 
muscle  cells  themselves,  or  to  the  influence  of  nerve  ganglia  in  the  uterus 
acting  on  the  muscle  cells  through  non-medullated  nerves. 

He  analyzed  the  contraction  curve  and  found  it  to  consist  of  three  parts  : 

1.  The  contraction. 

2.  The  maintenance  of  contraction. 

3.  The  relaxation. 

These  movements  were  strongest  and  most  prolonged  during  early  preg- 
nancy ;  weaker  in  the  puerperium  and  in  the  multiparous  uterus  ;  weakest 
in  the  virginal  state.  During  contraction  the  uterus  was  relatively  anemic, 
due  to  compression  of  vessels.  This  is  different  from  the  condition  in 
striped  muscle,  in  which  during  contraction  hyperemia  exists. 

Relaxation  after  contraction  was  shown  not  to  be  due  to  refilling  of  the 
blood  vessels,  because  it  was  noticed  in  an  excised  organ  when  there  was 
no  circulation.  Helme  believed  relaxation  to  be  due  either  to  elastic  reac- 
tion of  the  muscular  fibers  or  to  active  contraction  in  another  plane.  The 
arrest  of  the  arterial  supply  caused  immediate  contractions  of  the  uterus, 
followed  by  a  weakening  and  cessation.  Clamping  of  the  veins  caused  a 
slowing,  then  irregularity,  weakening,  and  cessation.  The  circulation  of 
venous  blood  caused  increased  strength  and  rapidity,  followed  by  gradual 
cessation.      Mechanical  irritation  caused  marked  contractions. 

The  physiology  of  the  uterus  in  the  human  female  is  not  as 
well  known  as  it  is  in  various  animals  which  have  been  subjected 
to  experimentation.  The  periodic  contractions  of  pregnancy  have 
already  been  described.  The  causes  determining  the  onset  of  the 
marked  contractions  that  initiate  the  phenomenaof  labor  in  normal 
cases  are  not  known.  They  take  place  entirely  involuntarily, 
though  they  may  be  inhibited  more  or  less  by  mental  conditions, 
especially  during  the  first  stage.  They  may  continue  in  various 
states  of  coma  or  anesthesia.  Irritation  of  the  nipples  may  often 
stimulate  them  reflexly.  Direct  massage  of  the  uterus  through 
the  abdominal  wall  increases  them. 

While  in  many  of  the  lower  animals  with  bicornute  uterus  the 
contractions  occur  as  peristaltic  waves  that  pass  from  the  outer 
ends  of  the  cornua  toward  the  vagina,  in  the  human  subject  no 
such  peristalsis  takes  place,  or  if  it  does  it  is  too  rapid  to  be  traced. 
The  hardening  of  the  uterus  appears  rather  to  take  place  in  all 
parts  of  the  active  segment  at  the  same  time,  there  being  at  first 


PHYSIOLOGY.  177 

a  period  of  increasing  intensity,  then  one  in  which  there  is  main- 
tenance of  the  most  marked  contraction ;  afterward  relaxation 
gradually  takes  place.  These  phases  vary  greatly  in  different 
stages  of  labor.  The  contractions  increase  in  duration  and  in- 
tensity as  labor  advances,  though  with  many  variations  in  different 
cases.  Intermittency  of  contractions  safeguards  the  life  of  the 
fetus.  Continued  activity  would  so  interfere  with  the  circulation 
as  to  endanger  the  normal  respiratory  processes  in  the  placenta. 
After  the  escape  of  the  liquor  amnii  these  risks  would  be  increased. 
During  well-marked  pains  the  body  of  the  uterus  stiffens  and 
moves  forward  somewhat.  It  has  been  stated  that  rotation  on  the 
long  axis  takes  place,  but  there  is  no  proof  of  this.  (In  the  sheep 
Helme  has  observed  coiling  of  the  outer  ends  of  the  cornua  and  a 
movement  toward  one  another  during  contractions.) 

The  relationship  of  the  uterus  to  the  cerebrospinal  and  sym- 
pathetic nervous  systems  has  been  already  noted.  Experiments  on 
animals  have  strongly  suggested  the  existence  of  an  excitory 
center  in  the  lumbar  region.  The  work  of  Schlesinger  and  others 
shows  that  stimulation  of  nerves  connected  with  the  lumbar  region 
can  reflexly  bring  about  uterine  contractions,  and  it  is  possible  that 
irritation  of  the  vagina,  cervix,  or  even  of  the  body  of  the  uterus, 
may  act  in  this  way.  Lusk,  Jacquemart,  and  others  have  reported 
cases  in  which  the  cord  has  been  destroyed  above  the  lumbar 
region,  labor  taking  place  naturally  afterward.  The  influence  of 
the  brain  on  the  lumbar  center  is  probably  one  of  an  inhibitory 
nature,  which  ordinarily  is  little  marked  in  comparison  with  the 
involuntary  activity  of  the  uterus. 

Mirabeau  has  recently  studied  a  case  of  labor  in  which  the 
mother  suffered  from  advanced  tabes  dorsalis.  There  was  absence 
of  the  patellar  reflex,  unconscious  micturition  and  defecation,  and 
complete  paralysis  of  the  lower  extremities  ;  sensory  impulses  were 
absent  as  high  as  the  bladder  and  rectum,  and  presumably  as  high 
as  the  uterus.  Labor  wasvery  easy,  the  pains  being  strong  ;  they 
were  not  felt  by  the  woman  ;  indeed,  the  cry  of  the  infant  was  the 
first  intimation  she  had  that  the  child  was  born.  From  this  case 
Mirabeau  concluded  that  the  uterine  activity  was  due  to  a  motor 
center  in  itself,  labor  continuing  though  the  nerve  arc  between  the 
uterus  and  lumbar  region  of  the  cord  was  destroyed. 

The  sympathetic  ganglia  in  the  uterus  are  probably  also  able 
to  induce  rhythmic  contractions.  Cases  in  which  contractions 
occur  after  the  death  of  a  woman  are  probably  those  in  which  the 
ganglia  determine  the  activity.  Experiments  on  animals  show 
clearly  that  rhythmic  contractions  may  take  place  in  the  uterus 
separated  from  the  body  if  it  be  kept  in  favorable  conditions.  It 
is  believed  by  many  that  irritation  of  the  uterus,  producing  con- 
tractions, may  act  through  these  ganglia,  but  it  is  also  possible 
that  such  stimulation  may  act  directly  on  the  muscular  tissue. 
12 


178      AM-ITOMV  AXD   PHYSIOLOGY  OF  NORMAL   LABOR. 

Whether  the  lumbar  center  or  the  uterine  gangUa  play  the  most 
important  part  in  inducing  and  continuing  labor  is  not  known. 
Probably  the  increased  activity  of  the  uterus  as  labor  progresses 
is  due  to  increased  stimulation  of  nerves  as  a  result  of  the  stretch- 
ing of  tissues  in  the  cervix  and  lower  uterine  segment ;  and,  after 
escape  of  the  liquor  amnii,  to  pressure  of  the  firm  fetus  against 
these  structures.  Various  attempts  have  been  made  to  estimate 
the  amount  of  force  exerted  by  the  uterus  during  contractions  and 
the  amount  necessary  to  rupture  the  membranes,  but  with  no  very 
satisfactory  results. 

How  much  of  the  uterine  wall  undergoes  contractions  at  the 
beginning  of  labor  is  not  definitely  known,  but  it  is  probable  that 
all  above  the  cervix  is  active.  As  the  first  stage  of  labor  advances, 
the  lower  uterine  segment,  becoming  stretched,  thinned,  and 
pressed  upon  by  the  bag  of  membranes  and  fetus,  probably  loses 
its  contractile  power  to  a  considerable  extent.  During  the  second 
stage — i.  c,  when  there  is  complete  canalization  of  the  cervix  and 
lower  uterine  segment,  the  latter  continues  to  be  practically 
passive  so  far  as  contractions  are  concerned.  The  active  contract- 
ing portion  is  the  upper  uterine  segment,  which  in  the  second 
stage  is  distinctly  thicker  than  the  lower  segment,  the  transition 
from  one  to  the  other  being  abrupt,  the  lower  edge  of  the  upper 
segment  forming  a  distinct  ridge. 

I  have  already  shown  that  this  ridge — variously  known  as 
Bandl's  ring,  retraction  ring,  contraction  ring — does  not  represent 
the  upper  limit  of  the  cen'ix  as  was  first  believed,  but  rather  the 
junction  of  the  upper  and  lower  segments  of  the  uterine  body. 
Bandl  believed  it  to  be  developed  in  obstructed  labor,  first  de- 
scribing it  in  a  case  of  ruptured  uterus,  and  he  regarded  it  as  placed 
at  the  upper  limit  of  the  thinned-out  cervix.  Now  it  is  known 
that  it  occurs  in  all  labors,  though  it  may  vary  as  regards  the 
degree  of  its  development.  It  was  termed  "  contraction  ring  "  by 
Schroeder,  who  regarded  it  as  the  lower  limit  of  the  active  con- 
tracting part  of  the  uterine  wall.  While  it  undoubtedly  does 
mark  the  lower  boundar}^  of  the  contracting  zone,  it  is  not  to  be 
regarded  as  due  to  the  contractions,  for  it  is  present  when  con- 
tractions are  absent — /.  c,  between  uterine  pains.  Lusk  suggested 
the  name  "  retraction  ring  "  as  more  satisfactorily  explaining  its 
formation.  He  pointed  out  that  it  is  really  the  lower  margin  of 
that  part  of  the  uterine  body  that  undergoes  the  change  termed 
retraction — viz.,  increasing  thickness  of  the  wall,  accompanied  by 
diminution  of  area,  a  process  that  is  persistent  during  labor  and  is 
to  be  distinguished  from  the  temporary  change  caused  by  con- 
traction. Barbour  is  a  strong  advocate  of  Lusk's  terminology,  but 
has  suggested  that  "  rim  "  or ''  edge  "  would  be  better  than  "  ring," 
since  its  true  nature  would  thus  be  suggested. 

Nature  of  Retraction. — There  is  considerable  uncertainty 


PHYSIOLOGY. 


179 


as  to  the  nature  of  uterine  retraction.  Some  have  held  that  it  is 
of  the  nature  of  an  elastic  recoil  in  the  musculature,  but  very 
little  importance  can  be  attached  to  this  factor,  for  the  elasticity 
of  the  muscle  is  very  slight,  and  there  is  little  true  elastic  tissue 
in  the  wall  outside  of  the  cervix.  Matthews  Duncan's  suggestion 
that  "  the  elasticity  of  the  peritoneal  covering  is  probably  the 
chief  element  in  the  elasticity  of  the  uterus  generally  "  cannot  be 
supported.  There  seems  to  be  little  doubt  that  the  thickening  of 
the  wall  termed  retraction  mainly  results  from  physiologic  activity 
in  the  muscle  fibers  that  cannot  be  considered  independently  of 


Fig.  93. — Diagrams  illustrating  different  conditions  of  muscle  :  a,  Biceps  extended 
to  fullest  extent;  b,  biceps  in  active  full  contraction;  c,  biceps  in  passive  full  relaxation 
(retraction)  (Horrocks). 

uterine  contractions.  Matthews  Duncan  and  others  have  held 
that  retraction  is  a  distinct  and  separate  function,  and  that  it  may 
go  on  without  contractions.  Most  hold,  however,  that  retraction 
is  dependent  upon  contraction,  being  in  fact  a  condition  of  perma- 
nent shortening  of  the  muscle  after  the  active  contraction  has 
passed  off  Helme,  in  experimenting  on  the  uterus  of  the  sheep, 
noted  that  after  each  contraction  the  relaxation  period  was  not 
complete — /.  e.,  there  was  a  certain  maintenance  of  contraction, 
the  individual  muscle  fibers  not  quite  returning  to  their  precon- 
tracted state. 

Horrocks   has  recently  elaborated  this  view.     He  points  out 


l8o      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL    LABOR. 


that  there  has  been  confusion  in  the  description  of  muscle  in 
various  states,  especially  as  regards  the  term  relaxation.  It  is 
necessary  to  distinguish  between  a  relaxed  shortened  muscle  and 
one  that  is  lengthened  and  relaxed.  In  all  probability  no  muscular 
fiber,  if  disconnected  from  its  usual  attachment,  is  capable  of  re- 
turning to  its  former  lengthened  condition.  Horrocks  instances 
the  experiment  of  stimulating  a  detached  frog's  muscle  placed  on 

mercury.  Extreme  shortening,  thicken- 
ing, and  hardening  is  produced ;  if  the 
stimulus  be  withdrawn  the  muscle  re- 
laxes but  remains  shortened,  though  less 
spheroidal.  Similarly,  when  the  biceps 
of  one's  arm  is  markedly  contracted  the 
muscle  becomes  short,  thick,  rounded, 
and  hard.  If  in  this  state  the  forearm  be 
supported  by  the  other  hand,  so  that  the 
hardening  of  active  contraction  disap- 
pears, a  relaxed  condition  of  the  muscle 
is  produced,  in  which  the  belly  is  still 
short  and  thick  though  much  less  marked 
than  during  active  contraction.  This  state 
of  relaxation  and  shortening  is  retraction. 
It  is  complete  when  it  occurs  after  the 
muscle  has  been  previously  shortened  by 


Fig.  94. — Diagram  illustrating  the  change  in  the  arrangement  of  the  muscular 
bundles  produced  by  labor  (Bumm)  :  a.  Condition  during  pregnancy ;  b,  condition 
after  delivery. 

active  contraction  as  much  as  possible  ;  partial  when  it  follows 
only  a  partial  contraction  of  the  muscle.  It  is  of  importance  to 
note  that  these  same  degrees  of  retraction  may  be  produced  with- 
out previous  active  contraction.  Thus,  if  from  a  state  of  complete 
extension  the  forearm  be  lifted  toward  the  shoulder  by  the  other 
hand,  without  any  voluntary  contraction  of  the  biceps,  the  muscle 
shortens  and  thickens  somewhat  though  remaining  relaxed,  and 


PHYSIOLOGY.  161 

corresponds  exactly  to  the  condition  in  which,  after  active  con- 
traction sufficient  to  raise  the  forearm  to  a  similar  position,  relaxa- 
tion occurred.  The  uterine  muscular  fibers,  like  all  others  in  the 
body  in  a  condition  of  health,  possess  a  certain  tone  and  tendency 
to  shorten.  In  the  majority  of  cases  this  is  counteracted  by  the 
action  of  opposing  muscles,  by  the  recoil  of  elastic  tissues,  the 
weight  of  structures,  etc.  The  pregnant  uterus  being  a  hollow 
muscle  filled  with  fluid  is  subjected  continually  to  a  certain  degree 
of  hydrostatic  resistance,  which  acts  equally  everywhere  at  right 
angles  to  the  containing  wall.  This  resistance  is  increased  during 
the  painless  contractions  that  occur  at  varying  intervals  through- 
out pregnancy,  and  it  prevents  the  uterus  from  remaining  retracted 
— i.  e.,  shortened  in  the  interval  of  relaxation. 

When  labor  begins  the  hydrostatic  pressure,  being  increased 
during  the  stronger  contractions,  gradually  causes  canalization  of 
the  lower  uterine  segment  and  cervix.  As  a  result  of  this  in- 
creasing weakness  in  the  lower  part  of  the  uterine  sac  there  is  a 
growing  tendency  toward  the  alteration  of  the  upper  segment  of 
the  uterus  by  retraction — /.  c,  the  relaxing  musculature  remains  a 
little  shortened.  In  the  great  majority  of  cases  this  change  is  not 
appreciable  so  long  as  the  membranes  are  firm  and  unbroken,  for 
being  elastic  their  retraction  after  each  pain  helps  to  make  up  for 
the  diminishing  support  of  the  lower  part  of  the  uterus.  Nor- 
mally toward  the  end  of  the  first  stage,  after  the  lower  portion 
of  the  membranes  has  been  repeatedly  stretched  and  thinned, 
the  beginning  of  retraction  in  the  upper  uterine  segment  may 
usually  be  noted.  In  abnormal  cases,  in  which  the  membranes 
rupture  prematurely  or  are  pouched  downward  through  the  cervix 
on  account  of  their  thinness,  the  area  of  hydrostatic  resistance  in 
the  uterus  is  lessened  and  retraction  of  its  musculature  follows. 
Normally  no  retraction  ridge  is  developed  during  the  first  stage  ; 
if  it  be  found  at  this  time,  it  is  probably  to  be  associated  with 
premature  escape  of  the  liquor  amnii  (as  in  W.  C.  Lusk's  case). 
The  ridge  may,  however,  be  developed,  though  there  be  long 
delay  in  rupture  of  the  bag  of  membranes,  after  the  second  stage 
has  commenced,  because  the  descent  of  the  bag  and  fetus  into  the 
pelvis  allows  marked  retraction  of  the  uterine  body  to  take  place. 
(See  Braune's  second-stage  case.) 

When  the  membranes  rupture  normally  the  characteristic 
retraction-changes  in  the  uterus  begin  to  be  clearly  marked.  As 
the  contractions  follow  and  the  child  descends  retraction  con- 
tinues ;  it  is  mainly  marked  in  the  upper  segment.  The  result  of 
the  process  during  that  part  of  the  second  stage  in  which  the 
fetus  descends  to  the  perineum  is  a  diminution  in  the  upper  uterine 
segment,  more  marked  circularly  than  longitudinally,  the  wall 
becoming  thickened.  (As  has  been  pointed  out,  the  height  of  the 
fundus  is  not  lowered  during  this  part  of  labor.)     The  process  is 


1 82      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL   L.ABOR. 

simply  one  in  which  there  is  a  rearrangement  of  the  bundles  of 
muscular  and  other  tissues  in  the  uterine  wall  as  the  latter  accom- 
modates itself  to  the  diminished  bulk  of  its  contents.  That  part 
of  the  upper  segment  on  which  the  placenta  is  situated  undergoes 
the  least  retraction,  probably  because  it  forms  a  mechanical  ob- 
struction to  a  reduction  in  size  caused  by  its  attachment.  The 
lower  segment  and  cervix  show  no  uniform  retraction  because 
their  tissues  are  continually  stretched  by  the  fetus.  Their  tissue 
may,  however,  retract  when  they  come  into  relation  with  an 
indentation  on  the  fetus — /.  c,  that  between  the  shoulder  and 
neck ;  in  such  a  relation  the  wall  thickens  and  fits  into  the  space. 
(See  Barbour  and  Webster's  second-stage  case.) 

A  comparison  of  different  frozen  sections  shows  that  there  are 
variations  in  the  thickness  of  the  upper  uterine  segment  caused  by 
retraction  in  labor.  In  each  case  the  thinnest  portion  is  that  to 
which  the  placenta  is  attached.  Irregularities  in  the  contour  of 
the  rest  of  the  wall  during  the  second  stage  are  due  to  unequal 
retraction,  depending  upon  variations  in  the  relationship  of  the 
wall  to  the  fetus.  During  the  second  stage  there  is  much  less 
liquor  amnii  in  the  uterus  than  during  the  first  stage  ;  it  mainly 
accumulates  in  the  fundal  region,  though  it  tends  to  fill  gaps 
caused  by  irregularities  in  the  fetus.  In  some  parts  these  irregu- 
larities are  filled  by  corresponding  bulgings  of  the  retracting 
uterine  wall  (well  shown  in  Barbour  and  Webster's  second-stage 
specimen).  The  position  and  thickness  of  the  retraction  ridge  also 
vary  in  different  cases,  but  the  explanation  of  the  variations  is  not 
always  certain.  The  more  prolonged  the  second  stage  the  higher 
it  tends  to  be  placed.  In  cases  of  badly  obstructed  labor,  due  to 
such  conditions  as  fetal  hydrocephalus,  impacted  transverse  pre- 
sentations, the  ridge  may  be  markedly  elevated  as  the  result  of 
excessive  retraction. 

Its  development  is  undoubtedly  affected  by  the  position  of  the 
placenta.  It  probably  does  not  form  in  that  part  of  the  wall  to 
which  the  placenta  is  attached  unless  the  latter  becomes  separated. 
In  Barbour  and  Webster's  second-stage  specimen  the  retraction 
ridge  followed  the  outline  of  the  lower  edge  of  the  placenta  and 
was  moulded  upon  it. 

The  most  marked  retraction  in  the  uterus  follows  the  birth  of 
the  child,  and  may  often  take  place  without  any  accompanying 
hardness  such  as  is  due  to  marked  contractions.  This  is  particu- 
larly exhibited  in  the  upper  uterine  segment,  but  is  also  found  in 
varying  degrees  in  the  lower  segment  and  cervix.  This  is  well 
shown  in  Pestalozza's  sections  of  the  beginning  of  the  third  stage. 
At  this  time,  also,  that  part  to  which  the  placenta  is  attached  is 
least  retracted.  (See  p.  216.)  Similarly,  in  cases  of  Csesarean 
section  where  the  operation  is  carried  out  before  labor  has  begun, 
incision  of  the  uterus  and  removal  of  its  contents  are  usually  fol- 


PHYSIOLOGY.  183 

lowed  by  immediate  retraction  of  the  uterine  wall,  which  becomes 
markedly  thickened,  without  any  accompanying  hardness,  such  as 
is  caused  by  active  contractions.  The  latter,  of  course,  may  after- 
ward take  place. 

Again,  as  Webster's  sections  demonstrate,  immediately  after 
the  placenta  and  membranes  are  delivered  further  retraction 
characterizes  the  whole  uterine  wall,  being  most  marked  in  the 
upper  segment,  less  in  the  cervix,  and  still  less  in  the  lower  seg- 
ment. Within  twenty-four  hours  the  latter  undergoes  such  re- 
traction as  to  be  obliterated.  The  part  that  changes  most  slowly 
is  that  immediately  above  the  cervix — viz.,  that  which  was  most 
stretched  and  thinned  in  labor. 

Mechanism  of  the  Canalisation  of  the  Cervix  and 
I^ower  Uterine  Segment. — The  following  factors  are  concerned 
in  this  process : 

I.  The  most  important  is  the  pressure  of  the  bag  of  waters. 
This  bag  is  formed  of  the  membranes  that  become  gradually  sepa- 
rated from  the  inferior  part  of  the  lower  uterine  segment,  because 
this  part  is  passive,  or  relatively  so,  as  compared  with  the  upper 
active  portion  of  the  uterus ;  it  contains  the  liquor  amnii  that  lies 
below  the  presenting  part  of  the  fetus.  The  membranes  are 
elastic  and  stretch  somewhat  under  pressure.  The  liquor  amnii 
transmits  the  force  of  uterine  contractions  equally  in  all  direc- 
tions, and,  as  the  least  resistant  part  of  the  containing  wall  is  the 
cervix  and  lower  uterine  segment,  gradual  increase  in  the  canal  of 
the  cervix  is  brought  about.  The  dilating  force  becomes  greater 
as  dilatation  advances,  for  the  hydrostatic  pressure  increases  with 
the  area  of  surface  against  which  it  is  directed.  The  os  internum 
is  gradually  obliterated  and  is  merged  in  the  lower  uterine  seg- 
ment, so  that  henceforth  the  obstructing  ring  is  the  os  externum. 
In  cases  in  which  there  is  premature  rupture  of  the  membranes, 
labor  is  delayed  because  canalization  is  slow.  The  presenting  part 
of  the  fetus  then  comes  directly  into  contact  with  the  cervix  and 
lower  segment,  and  is  a  much  less  satisfactory  dilator  than  the 
bag  of  waters. 

In  such  cases  a  caput  succedaneum  usually  forms,  and  this 
improves  its  dilating  power. 

2.  Relaxation  of  the  Tissues  of  the  Cervix. — The  increased 
softening  of  the  cervix  that  is  usually  noted  previous  to  labor,  and 
which  in  multiparae  is  often  associated  with  slight  dilatation  of  the 
canal,  becomes  intensified  when  labor  begins,  as  a  result  of  serous 
infiltration  of  the  tissues.  This  is  due  to  the  increased  hyperemia 
of  the  cervix  during  the  uterine  contractions.  The  softening  thus 
produced  greatly  facilitates  dilatation.  In  cases  of  placenta  prae- 
via,  where  there  is  excessive  vascularization  of  the  lower  uterine 
segment,  the  tissues  are  more  infiltrated  than  in  normal  cases  and 
dihitation    is    more    easily    accomplished.     The  vagina    becomes 


[84      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL   LABOR. 

softened  and    relaxed    in   a   similar   manner  and   usually  dilates 
slightly  before  the  bag  of  membranes  or  fetus  reaches  it. 

There  is  also  a  special  physiologic  relationship  between  the 
upper  uterine  segment  and  the  cervix,  termed  the  law  of  polarity, 
whereby  when  the  upper  part  contracts  the  cervix  relapses.  The 
lower  uterine  segment  also  shares  in  their  relaxation.  In  some 
cases  of  labor  this  law  is  not  observed,  abnormal  hardness  of  the 
cervix,  due  to  contractions  of  the  circular  muscular  fibers  in  it, 
occurring  regularly  or  irregularly  during  the  pains. 

3.  The  Upward  Traction  Exercised  by  the  Retracting  and 
Contracting  Upper  Portion  of  the  Uterus. — This  is  an  unimpor- 
tant factor  in  producing  dilatation,  and  probably  is  mainly  efficient 
in  the  latter  part  of  the  process.  Sections  show  that  the  position 
of  the  cervix  is  scarcely  altered  during  the  greater  part  of  the 
first  stage,  the  upward  traction  being  counteracted  by  the  thinning 
and  stretching  of  the  lower  uterine  segment.  Later  in  labor  the 
upward  traction  does  cause  some  elevation,  owing  mainly  to  the 
increase  of  retraction  in  the  upper  segment.  The  fundus  cannot 
sink  until  the  head  begins  to  pass  over  the  perineum,  because  the 
breech  of  the  fetus  remains  at  about  the  same  level,  as  a  result  of 
the  undoing  of  its  flexed  attitude.  The  upper  end  of  the  fetus 
(with  the  fundal  liquor  amnii)  offers  a  constant  point  d'  appui 
over  which  the  upper  segment  contracts  and  retracts.  Contrac- 
tion of  the  longitudinal  muscular  bundles  in  the  lower  uterine 
segment,  described  by  some  as  a  factor  in  dilating  the  cervix,  is 
probably  of  ver>^  slight  importance. 

4.  The  weight  of  the  uterine  contents  may  help  slightly  in 
dilating  the  cervix  if  the  woman  sits  or  walks  about  during  the 
first  stage ;  but  it  is  not  an  important  factor. 

BONY  PELVIS. 

An  exact  knowledge  of  the  bony  canal  is  necessary  to  the 
student  of  obstetrics.  The  detailed  account  of  its  constituent 
elements,  its  evolution,  its  function  in  protecting  the  viscera  and 
in  transmitting  the  weight  of  the  trunk  are  to  be  found  in  ana- 
tomic works.  Here  consideration  need  only  be  given  to  the 
pelvis  as  a  whole,  as  furnishing  a  bony  passage  through  which 
the  fetus  passes.  The  bony  pelvis  is  described  obstetrically  as 
consisting  of  two  parts — false  and  true. 

The  false  pelvis  is  that  part  that  lies  above  the  true  brim,  being 
made  up  of  the  iliac  wings  and  the  lower  lumbar  vertebrae.  The 
iliac  fossae  in  the  normal  pelvis  are  sometimes  compared  to  shallow- 
saucers.  In  the  erect  posture  their  inner  surface  looks  forward 
and  inward.  The  pelvic  brim  is  formed  by  the  upper  margin  of 
the  pubic  bones,  the  iliopectineal  lines,  and  the  upper  anterior 
edge  of  the  sacrum.  The  plane  bounded  by  this  line  is  an  irreg- 
ular one,  consisting  of  a  mesial  elevated  portion  extending  from 


BONY  PELVIS. 


185 


the  top  of  the  symphysis  to  the  sacral  promontory,  and  of  two 
lateral  parts  sloping  down  toward  the  rest  of  the  brim.      The 


Fig.  95. — Female  pelvis  seen  from  the  front  (one-third  natural  size). 

highest  part  of  the  plane  is  the  middle  of  the  promontory, 
which  is  about  an  inch  above  the  lateral  and  anterior  levels  of 
the  brim. 


Fu/Hlexed  tforsaf 

".J 


Sfra/ghf  cforsa/ 


/fang/ng  c/orsa/ 


Fig.    96. — Pulling   down    of  symphysis   and   longer   vera  in  hanging   dorsal   posture 

(Kiittner). 


1 86      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL   LABOR. 

The  shape  of  the  brim  in  the  aduh  female  may  be  roughly 
compared  to  the  heart  on  a  playing-card,  somewhat  modified. 
Normally  the  anteroposterior  measurement,  or  conjugate,  is  the 
shorter,  the  transverse  being  the  longer.  The  true  pelvis  is  that 
part  below  the  brim.  The  shortest  vertical  portion  of  its  wall  is 
straight,  and  is  formed  by  the  bodies  of  the  pubic  bones.  Later- 
ally the  wall  is  composed  of  the  ischial  bones  and  the  pubic  rami; 
it  slopes  inward  somewliat  from  the  brim  toward  the  lower  edge 
of  the  ischial  tuberosity.  Posteriorly  is  the  long,  curved  sacrum 
and  coccyx,  the  former  being  concave  anteriorly,  both  vertically 
and  transversely.  The  whole  canal  may,  therefore,  be  roughly 
compared  to  a  section  of  a  curved  cylinder,  of  which  the  bony 
wall  is  very  deficient  anteriorly. 


Fig.  97. — Female  pelvis,  viewed  from  below,  with  ligaments  (one-third  natural  size). 


On  each  side  the  bony  wall  is  incomplete.  Between  the  pubes 
and  the  ischium  is  the  obturator  foramen,  bridged  over  by  a 
fibrous  membrane  that  is  capable  of  being  bulged  slightly  out- 
ward. Between  the  ischium,  sacrum,  and  coccyx  are  the  strong 
great  and  small  sacrosciatic  ligaments.  Ordinarily  the  coccyx  is 
capable  of  being  moved  forward  and  backward  with  the  soft  parts. 

Outlet. — The  outlet  of  the  pelvic  cavity  is  lozenge-shaped, 
the  lower  margin  of  the  symphysis  being  in  front,  the  tip  of  the 
coccyx  behind,  and  an  ischial  tuberosity  on  each  side.  While 
anatomically  the  tip  of  the  coccyx  is  undoubtedly  the  postero- 
inferior  mesial  limit  of  the  bony  outlet,  for  obstetric  purposes  the 
lower  end  of  the  sacrum  may  be  so  regarded,  since  ordinarily  in 
labor  the  coccyx,  together  with  the  soft  tissues  of  the  sacral  seg- 


INCLINATION  OF   THE   PELVIS. 


187 


ment,  is  pushed  back  by  the  advancing  fetus.  The  anterior  bound- 
aries are  formed  by  the  lower  margins  of  the  subpubic  arch,  the 
posterior  by  the  sacrosciatic  Hgaments,  the  ischial  tuberosities  being 
on  a  lower  plane  than  the  rest  of  the  outlet.  The  transverse  diam- 
eter, measured  between  the  tuberosities,  is  nearly  an  inch  shorter 
than  the  transverse  diameter  of  the  brim,  and  the  conjugate  (with 


Fig.  98. — Female  pelvis  viewed  in  axis  of  brim. 

the  coccyx  bent  back  as  in  labor)  nearly  an  inch  larger  than  that 
of  the  brim. 

Inclination  of  the  Pelvis. — The  position  of  the  promon- 
tory varies  according  to  the  structural  peculiarity  of  the  pelvis 
and  according  to  the  posture.  If  a  series  of  bodies  be  studied  in 
the  erect  posture,  many  variations  may  be  noted.  The  angle  that 
the  anteroposterior  diameter  of  the  brim  makes  with  the  horizon 
is  generally  stated  to  be  about  55  degrees  ;  but  as  Barbour  has 
shown,  it  may  vary  from  35  to  65  degrees,  and  this  variation  is 
entirely  independent  of  the  length  of  the  anteroposterior  diameter. 
The  height  of  the  promontory  above  a  horizontal  plane  at  the  level 
of  the  top  of  the  symphysis  varies  from  2.6  to  5  in.,  the  average  being 
3.8  inches;  this  horizontal  plane  cuts  the  second  coccygeal  verte- 
bra, as  a  rule.  A  perpendicular  from  the  promontory  intersects 
the  horizontal  plane  at  a  point  2.4  to  4  in.  from  the  top  of  the 
symphysis,  the  average  being  2.8  in.  The  long  axis  of  the  upper 
part  of  the  sacrum  and  that  of  the  symphysis  are  generally 
regarded  as  being  nearly  parallel.  According  to  Meyer,  the 
inclination  of  the  pelvis  also  depends  upon  the  tension  of  the 
iliofemoral  ligaments,  diminution  of  inclination  occurring  when 
they  are  relaxed — /.  r.,  when  the  thighs  are  moderately  separated 


1 88      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL   LABOR. 

and  slightly  rotated  inward ;  increase  taking  place  on  closing  the 
knees,  rotating  the  thighs  outward,  separating  them  widely,  or 
markedly  rotating  them  inward.  He  believes  that  in  the  erect 
posture  the  center  of  gravity  of  the  trunk  passes  posterior  to  the 
middle  of  the  acetabula,  so  that  there  is  a  tendency  to  backward 
rotation  of  the  pelvis,  which  is  prevented  by  the  iliofemoral  liga- 
ments. 

Axis  of  the  Pelvic  Cavity. — The  axis  is  an  imaginary 
curved  line,  situated  midway  between  the  bony  walls  of  the 
cavity.     It  is  shown  in  the  accompanying  illustration  (Fig.  99), 


Fig.  99. — Diagram  of  pelvic  curve.  A,  In  the  bony  pelvis:  cd,  axis  of  inlet;  ab, 
horizontal  plane  ;  og,  anatomic  conjugate  of  outlet ;  cf,  axis  of  pelvis  or  curve  of  Carus. 
B,  In  the  pelvis  vv^ith  the  soft  parts  as  in  advanced  labor:  cf,  axis  of  pelvis;  r,  anus;  ab, 
line  drawn  from  symphysis  to  anterior  margin  of  perineum. 


which  represents  a  vertical  mesial  section  of  the  pelvis,  in  which 
is  drawn  the  brim  conjugate  and  a  series  of  anteroposterior  diam- 
eters from  the  lower  margin  of  the  symphysis  to  the  sacrum  and 
coccyx,  the  uppermost  of  which  is  parallel  to  the  conjugate  of 
the  brim.  By  joining  the  middle  points  of  these  lines  the  axis 
of  the  pelvis  is  obtained.  If  the  upper  part  of  the  axis,  which  is 
at  right  angles  to  the  brimi,  be  extended  downward  in  a  straight 
line,  it  usually  passes  through  the  lower  part  of  the  coccyx, 
whether  this  be  bent  back  or  not.  If  the  axis  of  the  outlet  be 
prolonged  upward,  it  passes  through  the  upper  part  of  the  first 
sacral  vertebra,  unless  the  coccyx  be  bent  back,  when  it  cuts  the 


MEASUREMENTS   OF   THE   BONY  EEL  VIS. 


189 


lower  part  of  this  vertebra ;  variations  are  found  according  to  the 
height  of  the  promontory  and  the  curve  of  the  sacrum  and  coccyx. 
It  is  usually  taught  that  this  axis  represents  the  direction  taken 
by  the  head  of  the  fetus  during  birth.  Generally  speaking  this  is 
true,  but  it  must  be  remembered  that  the  bony  cavity  is  modified 
by  the  soft  tissues,  and  that  the  axis  of  the  passage  along  which 
the  head  moves  (the  true  obstetric  axis)  must  be  somev/hat  differ- 
ent from  the  axis  of  the  bony  canal.  The  chief  difference  exists 
at  the  outlet,  where,  in  the  living  woman,  the  axis  is  anterior  to 
that  of  the  bony  pelvis,  owing  to  the  resistant  sacral  segment 
lying  in  front  of  the  coccyx. 

Measurements  of  the  Bony  Pelvis. — The  adult  pelvis 
presents   a  considerable   range   of  variations   in   size   and  shape 


Fig. 


-Effect  of  different  inclinations  of  pubis  upon  relationship  between  true  and 
diagonal  conjugate  diameters  (Ribemont-Dessaignes). 


within  the  limits  of  the  normal.  The  measurements  are,  there- 
fore, found  to  vary  somewhat,  the  following  figures  approximately 
representing  the  average  lengths  found. 

In  the  False  Pelvis — The  interspinous  or  interspinal  diam- 
eter, measured  between  the  ends  of  the  anterosuperior  iliac 
spines,  varies  from  9^  to  10  in.  (23.5  to  25.5  cm.).  The  inter- 
cristal  diameter  is  the  greatest  distance  between  the  summits  of 
the  iliac  crests,  and  varies  from  10^  to  11  in.  (26  to  28  cm.).  In 
normal  pelves  there  is  usually  a  fairly  constant  ratio  between  the 
above  diameters — viz.,  a  difference  of  about  i  in.  (2.5  cm.)  on  the 
average.  Marked  deviations  from  this  ratio  are  found  in  many 
abnormal  pelves. 

The  external  oblique  diameters  are  measured  respectively  be- 
tween the  postcrosupcrior  iliac  spine  of  one  side  and  the  antero- 


190      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL    LABOR. 

superior  iliac  spine  of  the  opposite.     They  are  termed  "  right " 
and  "  left"  according-  to  the  posterior  spine.     The  average  length 


Fig.  ioi. — Effect  of  different  thicknesses  of  symphysis  upon  relationship  between  true 
and  diagonal  conjugate  diameters  (Ribemont-Dessaignes). 

is  Sf  in.  (22  cm.).    A  slight  difference  between  these  may  be  found 
in  normal  cases ;  it  is  marked  in  certain  pelvic  abnormalities. 


Fig.   102. — Effect  of  different  heights  of  promontory  upon  relationship  between  true 
and  diagonal  conjugate  diameters  (Ribemont-Dessaignes). 

In  the  True  Pelvis. — {a)  Brim. — The  anatomic  conjugate  of 
the  brim  is  the  distance  between  the  middle  of  the  promontory 


MEASUREMENTS   OF   THE   BONY  PELVIS. 


191 


and  the  top  of  the  symphysis.     It  is  an  important  measurement, 
but   mainly   used  as   a  landmark   in   anatomic   descriptions.      It 


Fig.  103. — Effect  of  different  heights  of  symphysis  upon  relationship  between  true  and 
diagonal  conjugate  diaineters  (Ribemont-DessaignesJ. 

averages  about  4|-  in.  (12  cm.).     The  conjugata  vera — true,  ob- 
stetric, or  available   conjugate — represents   the  available  antero- 


FlG.  104. — a,  Average  elevation  of  promontory  in  a  series  of  frozen  sections  of 
cadavera  ;  b,  specimen  with  an  unusually  high  set  of  promontory  ;  c,  specimen  with  an 
unusually  low  set  of  promontory  (after  Barbour). 


posterior  space  at  the  brim  for  the  passage  of  the  fetus.     It  is 
measured  from  the  middle  of  the  promontory  to  the  nearest  point 


192      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL    LABOR. 

of  the  symphysis,  situated  slightly  behind  and  below  its  upper 
margin.  It  averages  about  4|  in.  (i  i  cm.),  and  is,  therefore,  about 
■^-^  in.  less  than  the  anatomic  conjugate. 

The  diagonal  conjugate,  measured  from  the  subpubic  ligament 
to  the  middle  of  the  promontory,  is  -|-  to  |-  in.  greater  than  the 
true  conjugate  in  normal  pelves.  Variations  in  the  relationships 
of  these  conjugates  are  mainly  due  to  differences  in  the  height  of 


Fig.  105. — View  of  posterior  aspect  of  normal  woman — partly  diagrammatic  (Bumm  ): 
a.  Prominence  of  lumbar  muscles;  b,  spine  of  fifth  lumbar  vertebra;  c,  Michaelis's 
lozenge;  d,  waist;  e,  iliac  crest  ;/i  posterosuperior  iliac  spine;  g,  line  of  attachment 
of  gluteal  muscles;  h,  trochanter. 


the  symphysis,  the  position  of  the  promontory,  and  the  angle 
between  the  vertical  axis  of  the  symphysis  and  the  conjugata  vera.' 
When  the  vertical  height  of  the  symphysis  is  more  than  \\  in., 
slightly  more  than  l  in.  should .  be  deducted  from  the  diagonal 
conjugate  in  estimating  the  vera.  In  flat  pelves,  where  the  height 
of  the  symphysis  is  greater  than  normal,  and  the  angle  between 
its  axis  and  the  true  conjugate  is  also  greater,  the  difference 
between  the  diameters  is  greater  than  normal. 


MEASUREMENTS   OF   THE   BONY  PELVIS.  I93 

In  the  majority  of  cases  a  conjugata  diagonalis  less  than 
4^  in.  (11.5  cm.)  indicates  anteroposterior  pelvic  contraction. 

The  transverse  diameter  is  the  greatest  distance  between  the 
iliopectineal  lines,  and  measures  about  5^  in.  (13.5  cm.).  The 
relationship  between  the  true  and  the  transverse  conjugates  is 
fairly  constant  in  normal  pelves,  the  latter  being  nearly  an  inch 
longer  than  the  former.  The  transverse  diameter  is,  on  the  aver- 
age, half  the  length  of  the  intercristal  (Sandstein). 

The  oblique  diameters  are  measured  respectively  from  each 
sacro-iliac  joint  to  the  iliopectineal  eminence  of  the  opposite  side. 
In  America,  Great  Britain,  and  Germany  they  are  termed  right 
and  left  according  to  the  sacro-iliac  joints ;  in  France  according 
to  the  iliopectineal   eminences.     The  average   length  of  each  is 


V 

o 

E 

Fig.  106. — Outline  diagram  showing  lozenge  of  Michaelis :   I,  In  the  female;   II,  in  the 
male,     a,  Last  lumbar  spme  ;  b,  posterior  superior  iliac  spine  ;  c,  coccyx. 

nearly  5  in.  (12.6  cm.);  usually  the  right  is  slightly  longer  than 
the  left. 

{b)  Cavity. — The  anteroposterior,  transverse,  and  oblique  diam- 
eters of  that  part  of  the  cavity  that  is  bounded  in  front  by  the 
symphysis  are  nearly  equal.  The  level  at  which  these  diameters 
are  taken  may  be  considered  as  passing  through  the  upper  edge 
of  the  third  sacral  vertebra  and  the  middle  of  the  symphysis. 
The  anteroposterior  and  transverse  diameters  measure  about  5  in. 
( 1 2.6  cm.).  There  are  no  fixed  points  between  which  to  draw  the 
obliques,  and  they  need,  therefore,  not  be  specially  considered. 
The  vertical  measurements  of  the  cavity  in  front  (the  height  of 
the  symphysis  pubis)  is  \\  in.  (3.8  cm.);  laterally,  from  the  brim 
to  the  lower  margin  of  the  ischial  tuberosity,  it  is  3^  in.  (8.9  cm.) ; 
posteriorly  the  vertical  distance  from  the  brim  to  the  tip  of  the 
coccyx  is  about  4I  in.  (10.8  cm.),  to  the  tip  of  the  sacrum  3I  in. 
(9.5  cm.).  The  vertical  measurement  of  the  sacrum  and  coccyx, 
following  its  curve,  is  about  5  in.  (12.7  cm.). 

{c)  Outlet. — The  anteroposterior  or  conjugate  diameters  are  the 
v.>, 


194      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL   LABOR. 

sacropubic,  drawn  from  the  lower  margin  of  the  symphysis  to  the 
lower  end  of  the  sacrum,  measuring  about  4^  in.  (12  cm.),  and 
the  pubococcygeal,  from  the  lower  edge  of  the  symphysis  to  the 
tip  of  the  coccyx.  The  latter  diameter  measures  in  the  dried 
pelvis  about  3^  in.  (8.9  cm.) ;  in  labor  the  coccyx  may  be  bent 
back  so  much  that  the  conjugate  becomes  4^  in. 

The  transverse  diameter  is  drawn  between  the  inner  borders 
of  the  ischial  tuberosities,  and  measures  4f  in.  (11  cm.). 

Oblique  diameters  need  not  be  described,  as  there  are  no  fixed 
points  between  which  they  can  be  drawn. 

The  distance  between  the  ischial  spines  is  4^  in.  (10.5  cm.). 

The  Pelvis  in  Relation  to  Surface  Markings. — The 
ordinary  surface  markings  of  the  pelvis  are  described  in  anatomic 
works.  Special  attention  must  be  given  to  the  back  of  the  pelvic 
region.  Here,  in  well-developed  normal  females,  a  lozenge- 
shaped  area  may  be  noticed.  The  lateral  angles  are  marked  by 
dimples,  about  5  cm.  from  the  middle  line,  situated  over  the 
postero-superior  iliac  spines.  The  upper  angle  is  formed  by  the 
spine  of  the  fifth  lumbar  vertebra  ;  the  lower  is  situated  over  the 
lower  part  of  the  sacrum,  near  the  coccyx,  where  the  gluteal 
muscles  approximate.  The  boundaries  of  the  upper  half  of  the 
lozenge  are  formed  by  muscles  of  each  half  of  the  back  ;  those 
of  the  lower  half  by  the  edges  of  the  glutei  muscles.  The  area 
is  well  shown  in  many  classic  statues.  Mjchaelis  was  the  first 
obstetrician  who  called  attention  to  it.  The  shape  varies  some- 
what in  different  conditions.  In  the  normal  woman  the  vertical 
and  transverse  diameters  are  almost  equal.  When  the  pelvis  or 
sacrum  is  narrow  the  lozenge  is  narrowed  transversely.  In  the 
male  the  transverse  diameter  is  shorter  than  in  the  female,  the 
lateral  angles  of  the  lozenge  being  consequently  larger. 

Physics  of  the  Pelvis  of  the  Adult  during  I<ife. — The 
amount  of  movement  at  the  joints  of  the  pelvis  during  life  is  very 
slight.  It  is  increased  during  pregnancy,  owing  to  the  increase  in 
the  synovial  fluid  and  to  the  softening  that  occurs  in  the  cartilages 
and  ligaments  during  that  period.  Occasionally  a  slight  up-and- 
down  movement  of  the  pubic  bones  at  the  symphysis  may  be 
detected,  especially  in  multiparas,  if  a  digital  examination  be  made 
while  the  woman  walks. 

The  weight  of  the  body  is  transmitted  through  the  sacru'm, 
which  is  attached  to  the  ossa  innominata  at  the  sacro-iliac  joints, 
where  it  is  slung  by  various  ligaments,  especially  by  the  strong 
posterior  sacro-iliac  ligaments,  which  extend  from  the  posterior 
iliac  spines  to  the  posterolateral  surface  of  the  sacrum.  The  old 
view  that  the  sacrum  is  related  to  the  pelvis  as  the  keystone  of  an 
arch  is  incorrect.  It  is  more  like  an  inverted  keystone,  since  it  is 
broader  toward  the  pelvic  cavity  than  toward  its  outer  surface. 
Owing  to  firm    ligamentous  attachments,  the  movement  of  the 


■      PHYSICS  OF  THE  PELVIS  OF  THE  ADULT  DURING  LIFE.    195 

sacrum  at  the  sacro-iliac  joints  is  very  slight;   but,  as  Zaglass 
first  pointed  out,  a  slight  amount  of  rotation  on  an  imaginary 


Fig.  107. — Frontal  section  through         FiG.  108. — Section  through  the  left  sacro-iliac 
symphysis  pubis,  exposing  interpubic  articulation  (Luschka). 

cleft  (Farabeuf). 

transverse  axis  may  occur.     Thus,  the  promontory  may  approach 
or  move  away  from  the  pubes,  the  lower  end  of  the  sacrum  being 


Full-Flexed 
dorsal 

Straight    dorsal 


ffang'ma  dorsat 


Fig.  109. — The  inlet  in  the  three  postures — smallest  in  full-flexed  dorsal,  longest  in 
hanging  dorsal  (Kiittner). 


correspondingly  moved  backward  or  forward.     Matthews  Duncan 
estimated   that  a   change  in   the  length   of  the  brim  conjugate^ 


196      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL   LABOR. 

amounting  to  \  in.,  might  thus  be  made.  During  defecation,  as 
the  body  is  bent  to  the  front,  the  promontory  is  tilted  forward. 
Before  the  head  has  entered  the  brim  in  labor  it  is  important  that 
the  body  should  not  be  doubled  up  in  any  way,  in  order  that 
there  may  be  no  diminution  of  the  conjugate. 

In  1889  Walcher  showed  that  the  greatest  possible  increase  in 
the  available  brim  conjugate  might  be  obtained  by  overextending 
the  body — /.  c,  by  placing  the  body  in  the  dorsal  position  on  a 
table,  the  thighs  being  allowed  to  hang  over  the  edge  so  that  the 
feet  do  not  touch  the  floor.  The  distance  from  promontory  to 
symphysis  in  this  position  is  ^  or  1  in.  greater  than  when  the 
thighs  are  well  flexed  over  the  abdomen. 

There  are  corresponding  changes  in  the  position  of  the  lower 
end  of  the  sacrum,  more  marked  because  it  is  farther  from  the 
transverse  axis  through  the  sacro-iliac  joints  than  the  promontory. 
The  sacropubic  conjugate  of  the  outlet  is,  therefore,  greatest  when 
the  thighs  are  well  flexed  on  the  belly ;  in  this  position  also  the 
ischial  tuberosities  are  slightly  pushed  apart  owing  to  the  influence 
of  the  wedge-shaped  sacrum. 

Male  and  Female  Pelves  Compared.— In  the  adult 
female   the   bones   are  smoother,  the  projections  being   less   de- 


/fanging  dorsa/ 

StraidM    dorsal 

^^  W^^''''""  Full-flexed    dorsal 
Sy/np/iya/s 

Fig.  iio.— The  outlet  in  the  three  postures— longest  in  the  fuU-fie.xed  dorsal  (KUttner). 


veloped  than  in  the  male  ;  they  are  of  higher  build  and  weigh  less. 
The  height  of  the  pelvis  is  less,  and  the  breadth  and  capacity  of 
the  true  pelvis  greater  ;  the  sacrum  is  wider  and  more  concave 
and  the  coccyx  more  movable ;  the  promontory  projects  more  in- 


MALE  AND   FEMALE   PELVES   COMPAl'lED. 


197 


ward  ;  the  anteroposterior  and  transverse  diameters  of  the  brim 
are  greater ;  the  subpubic  angle  is   larger.     It  is  generally  stated 


Fig.  III. — Male  pelvis  seen  from  the  front. 

that  the  subpubic  angle  measures  90  to  lOO  degrees  in  the  female, 
and  in  the  male  75  to  80  degrees.     These  figures  are  probably  too 


Fig.  112. — Male  pelvis  viewed  in  the  axis  of  the  brim. 


high.     Verneau  places  the  average  in  the  female  at  74  degrees, 
and  in  the  male  at  60.     In  the  female  the  tuberosities  of  the  ischium 


198      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL   LABOR. 

are  wider  apart ;  the  great  trochanters  are  more  separated.  In  the 
male  the  bones  are  thick  and  rough ;  the  brim  somewhat  triangu- 
lar ;  the  sacrum  long  and  narrow ;  the  cavity  funnel-shaped  ;  the 
subpubic  angle  narrow  ;  the  outlet  small. 

The  relationship  of  the  pelvis  to  the  shoulders  must  be  noted. 
It  has  long  been  believed  that  in  man  the  transverse  diameter  of 
the  shoulders  is  greater  than  that  of  the  hips,  while  in  woman  the 
latter  is  larger.  Duval  and  others  have  shown  that  in  the  Cau- 
casian race,  while  the  statement  is  true  as  regards  the  male,  it  is 
not  as  regards  the  female.  In  the  latter  the  two  diameters  are 
nearly  equal.  An  interesting  comparison  of  the  hips  of  American 
men  and  women  has  been  made  by  Sargent.  He  found  that  be- 
tween the  ages  of  seventeen  and  twenty  woman's  hips,  though 
relatively  4  in.  larger,  are  absolutely  smaller  than  man's  ;  at  the 
age  of  twenty  the  girth  of  the  hips  is  \  in.  smaller  in  women  than 
in  men  ;  but  when  measured  in  men  and  women  of  the  same 
height,  the  girth  averages  6  in.  more  in  women  than  in  men. 
With  reference  to  the  spine,  it  is  to  be  noted  that  the  lumbar  curve 
is  more  marked  in  women,  and  that  the  lumbar  region  is  rela- 
tively larger  than  in  men.  For  a  long  time  it  was  held  that  sexual 
distinctions  become  marked  in  the  pelvis  only  at  puberty.  In 
recent  years  they  have  been  demonstrated  at  a  much  earlier 
period.  Romiti  showed  that  at  birth  the  female  pelvis  is  more 
shallow,  has  more  curved  ilia,  and  a  wider  subpubic  angle  than 
the  male.  Jiirgens  made  a  comparison  between  birth  and  the  age 
of  five  and  noted  the  greater  size  of  the  female  pelvis,  especially  in 
the  transverse  measurements.  Fehling  demonstrated  differences 
at  the  very  beginning  of  ossification.  Professor  Thomson,  of  Ox- 
ford, has  made  an  elaborate  study  of  the  fetus  from  the  fourth 
month  of  intra-uterine  life,  and  has  shown  the  exact  nature  of  the 
differences  that  exist,  and  has  traced  the  relative  changes  from  the 
fetal  to  adult  life. 

Racial  Differences  in  Pelves. — The  highest  development  of 
the  female  pelvis  and  the  most  marked  differentiation  from  the 
male  pelvis  is  found  in  the  Caucasian  race.  In  the  lower  races 
there  is,  as  a  rule,  a  less  capacious  pelvis  and  more  resemblance 
to  that  of  the  male.  In  them  a  frequent  peculiarity  is  relative  in- 
crease of  the  conjugate  of  the  brim  as  compared  with  the  trans- 
verse. Thus,  in  native  Australian  women  the  brim  is  nearly  cir- 
cular; in  Bush  women  the  conjugate  is  longer  than  the  trans- 
verse. In  the  lower  races  the  sacrum  is  long,  narrow,  and  not 
much  curved,  the  condition  that  exists  in  the  apes.  The  broadest 
and  most  curved  sacrum  is  found  in  the  Caucasian  female.  (It 
is  interesting  to  note  that  along  with  the  evolution  of  the  pelvis 
there  has  been  a  corresponding  increase  in  the  size  of  the  fetal 
head.) 


THE   PASSENGER.  1 99 

THE  PASSENGER. 

In  the  first  stage  of  labor,  nominally,  it  is  not  the  fetus,  but  the 
bag-  of  membranes  with  its  contained  fluid  that  demands  attention. 
The  latter  consists  of  amnion  and  chorion,  with  remains  of  de- 
cidual tissue  on  its  lower  surface.  Often  it  consists  only  of  amnion 
in  its  central  area,  the  chorion,  which  is  not  as  tough  as  the 
amnion,  having  been  ruptured  and  forced  aside.  In  the  second 
stage  of  labor  the  fetus  is  the  moving  body  which  is  studied  in 
relation  to  the  genital  tract.  In  the  third  stage  it  is  the  placenta 
and  membranes. 

Fetus  at  Full  Time,  Obstetrically  Considered.— The 
chief  consideration  must  be  given  to  the  fetal  head,  because  it  is 
the  part  that  offers  the  most  difficulty  in  the  process  of  labor ;  it 
is  the  largest  and  most  solid  portion  of  the  fetus  ;  it  is  the  present- 
ing part  in  about  96  per  cent,  of  all  confinements  ;  abnormalities 
in  its  size,  shape,  position,  and  ossification  lead  to  increased  risk 
in  labor. 

Fetal  Head. — The  obstetrician  regards  the  head  as  made  of  a 
cranial  and  a  facial  portion. 

The  cranium  is  considered  in  two  parts — the  vault  and  the 
base.  The  former  is  composed  of  the  two  halves  of  the  frontal, 
the  two  parietals,  and  that  part  of  the  occipital  bone  that  lies 
above  the  foramen  magnum  ;  on  each  side  is  the  squamous  part 
of  the  temporal  bone.  The  vertex  is  that  part  of  the  cranium  be- 
tween the  coronal  and  lambdoidal  sutures,  extending  laterally  as 
far  as  the  parietal  eminences.  The  sinciput  is  the  portion  lying 
between  the  face  and  the  coronal  suture.  The  occiput  is  that  part 
behind  the  lambdoidal  suture.  The  base  is  made  up  of  the  basi- 
occipital,  the  sphenoid,  the  ethmoid,  and  the  petrous  portions  of 
the  temporal  bones. 

The  bones  of  the  vault  are  thinner  than  those  of  the  base,  more 
loosely  joined,  and  consequently  more  plastic.  In  labor  the  vault 
is  moulded  in  adaptation  to  the  pressure  exerted  upon  it  at  various 
parts  of  the  genital  passages  by  the  soft  and  hard  tissues  of  the 
pelvis.  There  are  many  variations  in  the  degree  of  plasticity  found 
at  full  time,  depending  upon  the  amount  of  ossification  in  the 
bones  and  the  looseness  of  the  sutures.  The  firmness  of  the  basal 
bones  is  a  guarantee  of  protection  for  the  important  brain  struct- 
ures lying  upon  them,  external  pressure  not  moulding  them  to 
any  appreciable  extent. 

The  sutures  of  the  vault  are  the  membranous  junctions  between 
the  bones.  The  most  important  are  the  sagittal,  frontal,^  coronal, 
and  lambdoidal.  The  fibrocartilaginous  junction  of  the  supra- and 
basi-occipital  must  be  noted ;  it  allows  the  supra-occipital  to  be 
bent  inward  somewhat  upon  the   basi-occipital  when  the  head  is 

1  Some  authorities  do  not  distinguish  a  frontal  apart  from  the  sagittal  suture,  in- 
cluding the  former  in  the  latter. 


200      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL   LABOR. 

moulded  in  labor.  Budin  has  laid  special  stress  on  its  importance 
in  this  connection. 

T\\&  fontanels  are  certain  membranous  areas  in  the  vault,  at  the 
junction  of  various  of  its  component  bones.  Of  these,  two  de- 
serve the  main  attention — the  anterior  and  posterior.  The  anterior 
fontanel  or  bregma  is  placed  at  the  junction  of  the  sagittal,  coro- 
nal, and  frontal  sutures.  It  varies  in  size  and  shape  in  different 
cases.  It  is  usually  lozenge-shaped  or  kite-shaped,  the  sharpest 
angle  being  anterior.  Ballantyne  has  found  the  average  antero- 
posterior measurement  to  be  2.7  cm. ;  the  average  width  between 
the  lateral  angles  being  2  cm.  Rarely  this  fontanel  may  be 
much  smaller  or  much  larger,  the  head  being  of  normal  size.  In 
hydrocephalus  it  may  be  very  large.  The  posterior  or  occipital 
fontanel  vs,  at  the  junction  of  the  sagittal  and  lambdoidal  sutures. 
Often  it  is  a  mere  triradiate  cleft  between  the  bones,  no  distinct 
space  being  appreciable.  In  other  cases,  when  ossification  is  less 
advanced,  there  may  be  a  small  triangular  space.  Ballant}'ne  has 
found  its  average  anteroposterior  length  to  be  8  mm.  In  labor, 
while  the  head  is  compressed,  the  space  may  not  be  recognizable 
owing  to  the  forcing  together  of  the  bones. 

The  temporal  fontanel  on  each  side  of  the  head,  at  the  junction 
of  the  temporal,  parietal,  and  occipital  bones,  is  of  little  obstetric 
importance  ;  occasionally  it  may  be  mistaken  for  the  posterior 
fontanel.  The  so-cdM^d  false  fontajiels  are  deficiencies  in  ossifica- 
tion in  the  main  thickness  of  the  bones  or  along  the  lines  of 
sutures.  Abnormalities  in  the  fontanels  and  sutures  may  occa- 
sionally be  produced  by  the  development  of  separate  small  masses 
of  bone,  known  as  Wormian  bones. 

Protuberances  or  Eminences. — The  following  are  to  be  noted  : 
The  glabella,  or  root  of  the  nose ;  the  frontal  eminence,  on  each 
side  of  the  forehead ;  the  parietal  eminence,  on  each  side  of  the 
cranium  ;  the  occipital  protuberance,  or  inion. 

Measurements. — The  following  anteroposterior  diameters  are 
important:  Occipitomental  (o.  m.),  from  the  tip  of  the  supra- 
occipital  bone  to  the  middle  point  of  the  chin. 

Occipitofrontal  (o.  f.),  from  the  occipital  protuberance  to  the 
glabella. 

Suboccipitobregmatic,  from  the  junction  of  the  neck  and  occi- 
put to  the  center  of  the  bregma ;  on  the  dried  skull  the  lower 
end  of  this  diameter  may  be  measured  from  a  point  midway 
between  the  foramen  magnum  and  the  occipital  protuberance. 
(Some  authorities  place  the  upper  end  at  the  anterior  angle  of  the 
bregma ;  others  at  the  posterior  angle.  My  own  view  is  that  a 
more  constant  point  is  the  exact  intersection  of  the  sagittal  and 
coronal  sutures.)  It  is  evident  that  if  a  series  of  suboccipito- 
bregmatic diameters  be  drawn,  they  diminish  in  length  from  before 
backward.     A  suboccipitofrontal  diameter  is  described  by  some 


PLATE  8. 


dipariml  \   ^cfjisph 


Verftex 


Ocap'tdPivtuh-  Mce 


"l^itcniDoral 


^- 


Fetal  skull  seen  (l)  from  the  side,  (2)  from  above,  (3)  from  behind,  and  (4)  fnnn  ni  front, 
sliowing  sutures,  fontanels,  and  diameters  (Dickinso)!). 


THE   PASSENGER. 


20 1 


extending  from  the  junction  of  the  occiput  and  neck  to  the  top 
of  the  forehead. 

Budin  has  described  another  anteroposterior  diameter,  which 
he  has  termed  the  supra-occipitomentai  or  viaxinmni  diameter. 
It  is  drawn  from  the  tip  of  the  chin  to  the  most  distant 
point  of  the  sagittal  suture,  situated  a  short  distance  above 
the  posterior  fontanel.  This  diameter  is  longer  than  the  occipi- 
tomental, the  difference  being  more  marked  after  labor  than 
before. 

The  transverse  diameters  are  as  follows  :  Biparietal  (bi-p),  from 
one  parietal  eminence  to  the  other ;  bitemporal  (bi-t),  between  the 
lower  ends  of  the  coronal  sutures  ;  bimastoid  (bi-m),  between 
the  mastoid  processes. 

The  vertical  diameters  are  rather  vaguely  defined.  The  fronto- 
mental  extends  from  the  top  of  the  forehead  to  the  lower  margin 
of  the  chin ;  the  cervicolaryngo-  or  trachelobregmatic ,  from  the 
center  of  the  anterior  fontanel  to  the  junction  of  the  chin  and 
neck,  near  the  larynx. 

Circumferences  of  the  head  are  measured  in  relation  to  the 
maximum,  the  occipitomental,  occipitofrontal,  and  suboccipito- 
bregmatic  diameters. 

The  measurements  vary  considerably  in  any  series  of  heads 
that  may  be  examined.  Some  variations  are,  of  course,  merely 
to  be  associated  with  individual  differences  in  size ;  others,  with 
the  condition  of  the  skulls  at  the  time  of  examination — /.  e., 
whether  unmoulded  or  moulded  by  labor ;  whether  dried  and 
bony  or  unaltered  and  covered  with  the  soft  tissues. 

Most  statistics  are  based  upon  studies  made  after  birth  ;  com- 
paratively few  from  measurements  of  unmoulded  heads,  as  obtained 
by  Caesarean  section  or  postmortem  examination.  The  following 
figures  may  be  taken  as  approximating  to  the  average.  They 
refer  to  the  skull  covered  by  the  soft  parts. 


Occipitomental  diameter  .    .    . 
Occipitofrontal         "  ... 

Maximum  "  .        . 

Suboccipitobregmatic  diameter 
Suboccipitofrontal  " 

Biparietal  " 

Bitemporal  " 

Bimastoid  " 

Frontomental  " 

Trachelobregmatic  " 

Occipitomental  circumference 
Suboccipitobregmatic      " 
Occipitofrontal  '* 

Maximum  " 


•  13- 


.5  cm. 

•5  ^'1 

3  '' 

7  " 


5    " 
5    " 


5    " 


4| 

4^ 

5i 

4tV 

4f 

Jl  6 
1    ^ 

2f 
Z\ 

31 
14 
"I 

i3f 
I4i 


When  the  dried  fetal  skull  is  measured  these  figures  are 
smaller.  The  changes  produced  by  moulding  in  labor  vary  ac- 
cording to  the  presentation  and  position  of  the   child  and  the 


202      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL    LABOR. 

peculiarity  of  the  mechanism.  They  will  be  described  in  con- 
nection with  the  various  forms  of  labor. 

Mobility  of  the  Head  on  the  Trunk — The  head  is  capable 
of  an  extensive  degree  of  movement  owing  to  the  plasticity  of 
the  joints  and  tissues  in  the  neck.  It  may  with  safety  be  bent 
almost  to  a  right  angle  on  any  side.  Tarnier  has  stated  that  the 
head  may  be  bent  backward  without  injury  until  the  face  looks 
almost  directly  backward.  Such  mobility  of  the  tissues  diminishes 
the  risks  to  the  fetus  in  many  cases  of  abnormal  and  artificial 
delivery. 

Trunk. — The  trunk  is  not  ordinarily  such  an  important  factor 
in  relation  to  labor  as  is  the  head.  Its  tissues  are  more  plastic 
and  compressible.  The  bisacromial  diameter  measures  about 
12  cm.  (4|- in.),  but  may  be  shortened  2  or  3  cm.  by  pressure. 
The  anteroposterior  chest  diameter  in  the  upper  part  is  8.5  cm. 
(3^  in.).  The  chest  circumference  averages  31  cm.  (12^  in.).  The 
bitrochanteric  diameter  is  9  cm.  (3^  in.).  The  anteroposterior 
pelvic  measurement  is  5.5  cm.  {2\  in.) ;  when  the  thighs  are  flexed 
on  the  abdomen  this  is  nearly  double.  The  circumference  of  the 
pelvis  is  about  26.6  cm.  (10^  in.) ;  with  one  thigh  flexed  on  the 
abdomen  it  is  about  30.5  cm.  (12  in.);  with  both  thighs  flexed 
33  cm.  (13  in.).  All  these  measurements  may  be  reduced  by 
compression. 

Summary  of  the  Stages  and  Factors  Concerned  in  Labor. 

{Powers — Uterus. 
Passages — Lower  uterine  segment  and  cervix. 
Passenger — Bag  of  membranes  and  forewaters. 
{Powers — Uterus  and  accessory  muscles. 
Passages — Genital  tract  and  cavity  of  pelvis. 
Passenger — The  fetus. 
(Powers — Uterus  and  accessory  muscles. 
Passages — Lower  uterine  segment,  cervix,  and  vagina. 
Passenger— Placenta  and  membranes. 

Attitude,  Presentation,  and  Position  of  the  Fetus  at 
the  beginning  of  I/abor. — Attitude — The  attitude  or  posture 
of  the  fetus  may  be  described  as  the  relationship  of  its  head, 
trunk,  and  limbs  to  one  another.  Normally  this  may  be  expressed 
by  the  term  "  flexion."  The  fetal  mass  presents  an  ovoid  shape. 
The  head  is  flexed  toward  the  chest,  the  arms  are  folded  on  the 
latter,  the  thighs  are  flexed  on  the  abdomen  and  the  legs  on  the 
thighs.  Many  variations  are  found.  Thus,  both  the  upper  and 
lower  extremities  may  be  placed  at  different  levels  and  differently 
arranged.  One  leg  or  both  may  not  be  flexed  on  the  thighs,  but 
may  be  extended  up  over  the  body.  The  face  does  not  always 
look  straight  downward,  but  may  be  turned  slightly  to  one  or  the 
other  side.  The  study  of  frozen  sections  has  shown  that  the  head 
is  usually  inclined  toward  one  shoulder,  whether  there  be  a  vertex 


ATTITUDE,    PRESENTATION,   AND  POSITION  OF  FETUS.    203 

or  a  breech  presentation.  These  variations  are  generally  produced 
by  movements  of  the  fetus,  but  in  some  cases  coiling  of  the  cord 
influences  the  disposition  of  the  limbs. 

Presentation. — This  term  is  ordinarily  used  to  imply  a  relation- 
ship between  the  long  axis  of  the  uterus  and  that  of  the  fetal 
ovoid,  as  well  as  to  indicate  that  part  which  is  in  the  axis  of  the 
parturient  canal.  In  times  past  various  views  have  been  held  as 
regards  normal  presentation.     Thus,  many  have  thought  that  the 


Fig.  113. — Fetus  from  a  case  of 
advanced  pregnancy.  The  inclina- 
tion of  the  head  toward  one  shoulder 
is  shown. 


Fig.  114. — Attitude  of  the  fetus  in  titer 0. 
A  specimen  from  an  eighth-month  preg- 
nancy (Barbour  and  Webster). 


anterior  fontanel  normally  presented.  Roederer  believed  it  to  be 
the  occiput ;  Naegele  taught  that  it  was  the  parietal  region  of  the 
head  that  was  anteriorly  placed. 

At  the  present  day  it  is  generally  taught  that  in  normal  cases 
— /.  c,  about  96  per  cent,  of  all  labors,  the  long  axis  of  the  fetal 
ovoid  is  parallel  with  that  of  the  uterus,  the  head  being  lower- 
most, the  vertex  being  the  presenting  part.  Further,  it  is  held 
that  the  sagittal  suture  of  the  head  crosses  the  axis  of  the  pelvis, 
the  occipitofrontal  plane  being  parallel  with  the  plane  of  the  brim. 


204      ANATOMY  AND  PHYSIOLOGY  OF  NORMAL   LABOR. 

These  statements  are  based  upon  clinical  examination,  a  method 
of  inquiiy  that  is  not  thoroughly  rehable  in  the  determination  of 
anatomic  relationships.  With  the  fingers  it  is  very  difficult  to 
make  out  exactly  how  the  presenting  part  is   placed  in  relation  to 


Fig. 


IIS- 


-Attitude   of  the   fetus  in  utero.      Each   of  these   is  a   full-term    specimen 
(Barbour). 


the  brim,  because  the  area  that  is  palpated  is  comparatively  small. 
It  is  impossible,  for  example,  in  the  living  woman  to  place  the 
finger  in  the  exact  axis  of  the  pelvic  cavity  and  to  determine  always 
accurately  the  relation  of  the  sagittal  suture  to  it. 


Case. 


Braune  and  Zweifel 
Pinard  and  Varnier  . 


Barbour      

Winter 

Saxinger     

Barbour  and  Webster 

Pestalozza 

Leopold 


Primipara. 

Bipara. 

Sextipara. 

Bipara. 

Primipara. 

Multipara. 

Sextipara. 

Primipara. 


Period. 


9    months. 

8 

First  stage. 


Distance  of 
verte.x  be- 
low brim. 


2-S 

2.25 
2.4 

2.75 
2-75 
2.25 

2.75 
2.50 
1.62 


Proportion  of  posterior 
half  of  head  lying  within 
conjugate  of  brim. 


3. 87  in.  out  of  7  in. 


6 
7  in. 

7-75  i"- 
7.1  in. 
6.04  in. 
7.25  in. 
7  in. 
4.75  in. 


It  is  only  by  fixing  the  parts  ?';/  situ  and  examining  them  un- 
disturbed that  the  truth  can  be  ascertained.  In  recent  years  this 
has  been  done  by  the  freezing  method,  and  it  has  been  clearly  de- 
monstrated in  a  number  of  cases  that  the  occipitofrontal  is  not 
exactly  parallel  with  the  plane  of  the  brim,  and  that  the  center  of 
the  vertex  and  the  sag-ittal   suture  are  not  in  the  axis  of  the  inlet. 


ATTITUDE,    PRESENTATION,    AND   POSITION  OE  EETUS.    205 

The  sagittal  suture  is  either  anterior  or  posterior  to  the  axis, 
usually  in  front,  and  a  larger  part  of  one  parietal  bone  is  at  a 
lower  level  than  of  the  other.  Barbour  has  emphasized  this  pecu- 
liarity, and  has  drawn  up  a  table  of  measurements  made  in  dif- 
ferent cases  of  frozen  sections  (see  page  204). 

In  6  out  of  9  cases  more  of  the  posterior  half  of  the  head  than 
of  the  anterior  lay  below  the  plane  of  the  upper  part  of  the  pelvic 
cavity. 

De  Seigneux,  from  a  clinical  study  of  80  consecutive  cases, 
states  that  three  varieties  of  presentation  are  to  be  regarded  as 
normal — viz:  [a)  Anterior  parietal  in  22.5  per  cent.;  [J?)  posterior 
parietal  in  53.75  per  cent.;  \c)  vertex  orsynclitic  in  23.75  percent. 

He  believes  that  the  dimensions  of  the  pelvis  have  little  to  do 
with  the  presentation.  In  his  series  the  pelves  were  normal  except 
4  in  group  a  (i  justominor  and  3  rickety  flat),  5  in  group  b  (2  rickety 
fiat,  2  justominor,  i  non-rickety  flat),  and  i  justominor  in  group  c. 

He  thinks  that  presentation  is  mainly  determined  by  the  in- 
clination of  the  uterine  axis  to  the  plane  of  the  pelvic  brim. 
Thus,  posterior  parietal  presentations  are  more  common  in  primi- 
parae  because,  owing  to  the  tenseness  of  the  abdominal  wall,  the 
uterus  is  held  back  against  the  spine,  while  anterior  (Naegele) 
presentations  are  more  common  in  multiparae  with  lax  abdominal 
wall  and  anteverted  uterus.  Pelvic  contraction  acts  indirectly 
only  by  favoring  anteversion,  which  condition  is  aggravated  by 
laxity  of  the  abdominal  wall. 

Barnes,  Galabin,  Fritsch,  and  many  others  also  hold  that  ob- 
liquity is  not  to  be  regarded  as  an  abnormality.  Schatz  agrees  with 
this  view,  but  states  that  it  is  most  marked  when  the  pelvis  is  flat. 

In  multiparae,  at  the  onset  of  labor,  the  presenting  portion  of 
the  head  is  at  or  a  little  above  the  brim  level  ;  occasionally  it  is 
found  partly  below.  In  primiparae,  in  normal  conditions,  it  is 
within  the  pelvic  cavity.  The  plane  of  the  head  that  is  related  to 
the  planes  of  the  upper  part  of  the  pelvic  cavity  varies  in  different 
cases.  Often,  especially  in  multiparae,  it  is  the  occipitofrontal. 
In  many  cases,  in  which  the  head  is  subjected  to  unusual  surround- 
ing resistance,  the  occiput  is  somewhat  lower,  the  plane  being  more 
suboccipitofrontal. 

Position — This  is  the  relation  of  the  presenting  part  to  the 
pelvis  of  the  mother.  In  vertex  presentations,  at  the  beginning 
of  labor,  when  the  pelvis  is  normal,  this  relationship  is  such  that 
the  anteroposterior  diameter  of  the  head  is  more  or  less  in  line 
with  an  oblique  diameter  of  the  pelvis.  This  is  often  termed  the 
Solayres  obliquity.  It  is  evident,  therefore,  that  the  head  may 
occupy  any  one  of  four  positions.  These  are  usually  demonstrated 
in  terms  of  the  occiput,  which  may  lie  to  the  front  and  left  or  to 
the  front  and  right  of  the  middle  line,  to  the  back  and  right  or  to 
the  back  and  left  of  the  middle  line.     Some   authors   regard  the 


2o6      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL    LABOR. 

brim  as  divided  into  four  quadrants  by  the  intersection  of  the 
conjugate  and  transverse  diameters,  and  describe  the  occiput  as 
lying  in  one  or  other  of  these  quadrants. 

There  are  no  fixed  points  in  the  pelvis  toward  which  the  occi- 
put is  directed.  Generally  it  is  stated  that  when  it  is  anterior  it 
is  opposite  the  ihopectineal  eminence,  and  when  posterior  oppo- 
site the  sacro-iliac  joint.  There  are,  however,  many  deviations. 
Occasionally,  indeed,  the  anteroposterior  may  correspond  more 
nearly  to  the  transverse  than  to  the  obHque  diameter  of  the  pelvis. 
The  four  positions  described  may  be  named  as  follows :  Occipito- 
laeva  anterior  (O.  L.  A.),  occipitodextra  posterior  (O.  D.  P.),  occip- 
itodextra  anterior  (O.  D.  A.),  occipitolaeva  posterior  (O.  L.  P.). 

As  regards  the  relative  frequency  of  these,  the  following  statis- 
tics are  given : 

Position.  Naegele.    Naegele,  Simpson  and      Dubois.  Murphy.     Swayne. 

Jr.  Barry. 


O.  L.  A.  79             64            76  70                63             86 

O.  D.  p.  29            32             25  25                 16               I 

O.  D.  A.                                               0.2  2169 

O.  L.  P.                    -                           0.5  0.6  4              2 


A  working  estimate  may  be  roughly  summarized  thus :  O.  L.  A. 
in  74  per  cent,  of  vertex  presentation  ;  O.  D.  P.  in  20  per  cent. ; 
O.  D.  A.  in  5  per  cent. ;  O.  L.  P.  in  i  per  cent. 

It  must  be  remembered  that  occipitoposterior  cases  generally 
change  into  occipito-anterior  during  labor,  and  are  likely  to  be 
recorded  as  the  latter  if  examination  be  made  at  too  late  a  period. 

Diagnosis  of  Vertex  Presentations. — Occipito=anterior 
Positions, — The  diagnosis  of  occipito-anterior  positions  in  vertex 
presentations  is  easily  determined  in  the  great  majority  of  cases 
by  external  examination.  On  palpating  the  abdomen  of  the 
mother  the  back  of  the  fetus  is  felt  as  a  smooth,  firm  area  without 
projections,  close  to  the  anterior  wall  of  the  uterus,  the  thoracic 
part  of  the  back  being  more  to  the  left  or  right  of  the  middle  line 
according  to  the  position.  The  firm,  round  head  is  felt  at  the 
brim  of  the  pelvis,  variations  being  found  in  the  portion  that  can 
be  felt  above  the  brim.  Thus,  in  primiparas,  in  whom  the  head 
sinks  considerably  within  the  pelvis,  during  the  last  month  of 
pregnancy  very  little  may  be  palpated  externally.  Owing  to  the 
flexed  attitude,  more  of  the  sinciput  than  of  the  occiput  lies  above 
the  brim.  Sometimes  the  lower  jaw  or  even  supra-orbital  ridge 
may  be  palpated.  A  sulcus  may  usually  be  determined  between 
the  prominence  of  the  anterior  shoulder  and  the  head,  from  i  to  2 
in.  to  the  left  or  right  of  the  middle  line,  a  short  distance  above 
the  inner  end  of  Poupart's  ligament.  When  the  head  lies  above 
the  brim,  it  may  usually  be  moved  in  different  directions  if  the 
uterus  be  not  contracting,  especially  when  there  is  abundant  liquor 
amnii.  When  it  has  partly  entered  the  pelvis,  it  may  often  be 
slightly  elevated,  but  cannot  be  moved  in  a  transverse  or  antero- 


DIAGNOSIS    OF    VERTEX  PRESENTATIONS.  20/ 

posterior  plane.  When  it  has  deeply  descended  into  the  pelvis,  it 
cannot  be  moved  by  abdominal  palpation.  Fixation  does  not 
usually  take  place  until  the  biparietal  diameter  has  passed  the 
brim.  The  upper  fetal  pole  is  situated  at  the  fundus  uteri,  and 
consists  of  the  breech  and  lower  limbs  or  of  the  breech  alone. 
With  the  feet  the  breech  may  form  a  mass  as  large  as  the  head, 
but  of  irregular  contour ;  the  breech  alone  is  smaller  than  the 
head,  less  round  and  not  so  firm.  No  sulcus  exists  between  it 
and  the  body,  and  it  cannot  be  moved  by  ballottement,  as  the  head 
may  be,  when  it  is  situated  at  the  fundus  uteri.  The  back  is  felt 
firm  and  smooth  and  may  be  arched  forward,  as  Budin  has  pointed 
out,  when  the  fetal  poles  are  approximated  by  pressure  on  the 
fundus.  When  the  placenta  intervenes  between  the  examining 
hands  and  the  fetus,  the  latter  cannot  be  distinctly  felt. 

The  heart  of  the  fetus  is  heard  through  the  abdominal  wall  of 
the  mother  between  the  umbilicus  and  Poupart's  ligament,  on  the 
left  side  in  O.  L.  A.  positions,  on  the  right  side  in  O.  D.  A.  positions. 
The  point  of  maximum  intensity  of  the  heart  sounds  corresponds 
to  the  lower  angle  of  the  left  fetal  scapula.  •  It  is,  therefore,  at  a 
lower  level  in  women  (/.  c,  primiparse)  in  whom  the  head  is  con- 
siderably below  the  pelvic  brim  at  the  beginning  of  labor  than  in 
those  in  whom  it  is  mainly  above.  It  must,  however,  be  remem- 
bered that  the  point  at  which  the  heart  is  heard  most  loudly  may 
not  correspond  to  the  lower  angle  of  the  left  scapula ;  it  may  only 
be  that  part  of  the  fetal  chest  that  happens  to  be  most  closely 
applied  to  the  uterine  wall.  In  the  great  majority  of  cases  the 
abdominal  examination  is  sufficient  to  determine  the  relationships 
of  the  fetus.  It  may  fail  when  the  abdominal  wall  is  very  fat  or 
tense,  when  the  uterus  is  very  firm  or  much  distended,  or  when 
various  pathologic  conditions  are  present — i.  e.,  a  tumor.  Vaginal 
examination  is,  therefore,  rarely  necessary.  Per  vaginam  before 
dilatation  of  the  cervix  it  is  usually  only  possible  to  feel  the  hard, 
rounded  head.  After  the  cervix  is  partly  dilated  it  is  possible  in 
some  cases  to  determine  the  position  of  the  sutures  or  fontanels, 
but  generally  this  can  only  be  satisfactorily  accomplished  after 
rupture  of  the  membranes.  The  sagittal  suture  is  usually  first  felt 
by  the  finger ;  the  anterior  and  posterior  fontanels  may  sometimes 
be  felt  before  the  head  has  well  descended.  At  a  later  stage 
usually  only  the  posterior  fontanel  may  be  touched  ;  it  lies  to  the 
left  or  right  of  the  middle  line  according  to  whether  the  position 
is  O.  L.  A.  or  O.  D.  A.  Ordinarily  the  fontanels  are  easily  dis- 
tinguished ;  when  the  anterior  is  small  or  compressed  it  may  be 
mistaken  for  the  posterior.  It  is  important  in  cases  of  difficulty  to 
determine  the  number  of  sutures  entering  into  the  fontanel ;  three 
in  case  of  the  posterior,  four  in  case  of  the  anterior.  Abnormal 
deficiencies  in  the  bone  may  easily  be  mistaken  for  the  fontanels, 
and  Wormian  bones  may  be  misleading. 


208      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL    LABOR. 

Sometimes  a  large  caput  succedaneum  may  make  it  difficult 
to  feel  the  sutures  and  fontanels.  When  the  cervix  is  well  dilated 
and  the  membranes  ruptured,  it  may  sometimes  be  advisable  to 
push  the  fingers  up  behind  the  pubes  in  order  to  locate  an  ear. 
In  canying  out  these  manipulations  it  is  well  to  steady  the  fundus 
and  upper  pole  of  the  fetus  with  the  outer  hand. 

MECHANISM  OF  LABOR. 

Vertex    Presentation. — Occipitolasva    Anterior. — In    the 

most  common  form  of  labor — viz.,  that  in  which  the  vertex  pre- 
sents (O.  L.  A.),  the  head  makes  a  series  of  movements  in  its 
passage  through  the  pelvis  that  are  generally  described  as  the 
"  mechanism  of  labor."  It  is,  therefore,  to  be  applied  mainly  to 
the  second  stage,  though  it  must  be  remicmbered  that  in  some 
cases  these  movements  may  begin  before  the  cervix  is  fully  dilated  ; 
this  is  mainly  found  when  the  head  lies  partly  within  the  pelvis 
before  labor  begins — i.  e.,  in  primiparae.  These  movements  of 
accommodation  are  necessary  to  the  passage  of  the  head  with  the 
least  difficulty,  and  they  result  partly  from  the  shape  of  the  head, 
partly  from  the  shape  of  the  hard  and  soft  canals.  Owing  to  the 
variations  that  these  factors  may  present,  the  movements  vary 
somewhat  in  different  cases,  though  in  general  the  main  features 
of  the  mechanism  are  usually  present.  At  the  present  time  it  is 
customar>^  to  describe  the  movements  as  follows  :  Flexion  ;  inter- 
nal rotation ;  extension  ;  external  rotation  or  restitution  of  the 
head  ;  expulsion  of  the  trunk. 

Descent  has  been  mentioned  by  man}'  writers  as  one  of  the 
movements,  but  this  is  unnecessaiy,  since  it  goes  on  throughout 
the  whole  second  stage,  and  the  movements  take  place  merely  to 
facilitate  descent. 

Synclitism  was  a  term  used  by  older  authors  to  imply  that 
there  was  a  series  of  parallelisms  between  certain  planes  of  the 
head  and  certain  planes  of  the  pelvis.  Such  a  term  is  unneces- 
sary, employed  in  this  sense.  If  used  in  the  general  sense  of 
adaptation,  no  objection  may  be  raised,  for  it  is  self-evident  that 
the  mechanism  of  labor  is  but  a  series  of  adaptations  of  the  fetus 
to  the  parturient  canal.  The  idea  of  special  planes  is  a  creation 
of  the  imagination  entirely  unsupported  by  anatomic  investigation, 
and  must  be  abandoned.  The  exact  relationships  of  the  head  at 
the  beginning  of  labor  have  been  fully  described.  During  the 
first  stage  it  does  not  ordinarily  change  much.  After  the  cervix 
is  dilated  and  the  membranes  ruptured,^  it  descends  so  as  to  be 

1  In  some  cases  in  which,  after  the  cervix  is  fully  dilated,  the  membranes  do  not 
rupture  but  remain  and  stretch  before  the  advancing  head  (as  in  Braune's  and 
■Chiari's  specimens),  the  mechanism  of  the  second  stage  may  continue,  though 
somewhat  more  slowly  than  normal. 


MECHANISM   OF  LABOR.  20g 

embraced  by  the  lower  uterine  segment,  and  m.eets  the  resistance 
of  the  bony  canal  (if  it  has  not  already  been  lying  partly  within 
it).  The  ordinary  normal  movements  may  now  be  noticed  in 
detail. 

Flexion. — The  current  views  concerning  this  movement  must 
be  modified  as  a  result  of  recent  studies  of  the  anatomy  of  labor 
by  means  of  frozen  sections.  The  term  has  long  been  regarded 
as  a  dipping  of  the  occipital  end  of  the  head,  due  to  a  bending 
of  the  chin  on  the  chest,  the  object  being  to  bring  a  smaller 
diameter  of  the  head — viz.,  a  suboccipitobregmatic,  into  relation 
with  the  girdle  of  resistance.  Here  again  clinical  examination 
has  erred  in  trying  to  establish  anatomic  data,  and  has  succeeded 
only  in  substituting  speculation  for  facts.  By  the  fingers  it  is  im- 
possible to  determine  accurately  what  takes  place  above  the  girdle 
of  contact — /.  c,  that  part  of  the  head  embraced  by  the  soft 
passage  at  any  level ;  it  is  impossible  to  determine  how  the  chin 
of  the  fetus  moves.  All  that  can  be  made  out  by  digital  exami- 
nation is  what  takes  place  within  and  below  the  girdle  of  contact. 
Certain  it  is  that  in  many  cases  a  change  occurs  whereby  the 
occiput  descends  more  than  the  sinciput,  the  posterior  fontanel 
becoming  relatively  lower  than  the  anterior  fontanel,  but  this 
might  be  brought  about  by  a  rotation  of  the  whole  fetus  on  a 
transverse  axis  as  well  as  by  the  bending  of  the  chin  on  the 
sternum. 

Now,  the  facts  derived  from  the  study  of  bodies  frozen  in 
various  stages  of  labor  show  that  the  chin  is  fairly  constant  in 
relation  to  the  sternum  throughout  labor  until  the  head  begins  to 
pass  through  the  vulva.  Barbour,  who  has  made  a  careful  study 
of  this  subject,  states  that  flexion  in  labor  is  to  be  regarded  as  an 
attitude,  as  it  is  in  pregnancy,  rather  than  as  a  movement.  He 
doubts  if  it  is  justifiable  to  speak  of  it  as  a  movement  of  labor  at 
all,  but  he  does  not  imply  that  a  movement  of  flexion  may  not 
occasionally  occur;  there  may  be  a  disturbance  of  the  normal 
attitude  of  the  head,  as  of  any  other  part  of  the  body,  and  this 
alteration  may  be  corrected  by  a  movement  of  flexion.  The  close 
relationship  of  the  chin  to  the  sternum  in  the  advanced  second 
stage  of  labor  is  well  shown  in  Barbour  and  Webster's  case 
(Fig.  114). 

It  is  probable  that  in  many  cases  the  change  in  the  position  of 
the  occiput,  as  a  result  of  the  movement  to  be  next  described — 
viz.,  internal  rotation,  is  misinterpreted  as  a  marked  dipping  of  the 
posterior  fontanel,  or  flexion.  When  the  head  is  already  partly 
within  the  bony  cavity  at  the  beginning  of  labor,  internal  rotation 
very  soon  brings  the  occiput  into  relation  with  the  deficiency  of 
the  bony  pelvis  anteriorly,  and  being  more  easily  palpated  it  may 
very  easily  be  regarded  as  having  descended  markedly.  In  some 
cases  it  may  be  easily  determined  by  clinical  examination  that  no 
u 


2IO      ANATOMY  AXD   PHYSIOLOGY  OF  NORMAL    LABOR. 

increased  flexion  occurs  at  all  in  labor — /.  r.,  in  roomy  pelves  or 
when  the  head  is  small.  The  most  marked  dipping  of  the  occiput 
has  been  noted  when  the  head  meets  with  pronounced  surround- 
ing resistance  either  on  the  part  of  the  soft  or  hard  tissues.  It 
occurs  at  different  levels  in  different  cases.  Many  theories  have 
been  advanced  to  explain  how  flexion  occurs,  but  in  view  of  the 
recent  criticisms  as  to  the  nature  and  occurrence  of  this  phe- 
nomenon they  need  not  be  discussed. 

The  necessity  that  has  always  been  urged  in  connection  with 
the  supposed  movement — viz.,  the  substitution  of  a  shorter  cir- 
cumference of  the  head  for  a  long  one,  does  not  probably  exist  in 
the  majority  of  normal  labors,  because,  owing  to  the  attitude  of 
the  fetus  early  in  labor,  a  sufficiently  small  circumference  is  in 
relation  to  the  parturient  canal.  In  cases  in  which  the  head  is 
abnormally  large  or  the  canal  small,  the  more  rapid  descent  of 
the  occipital  end  of  the  head  does  substitute  a  smaller  circumfer- 
ence of  the  head,  and  it  is  probably  due  to  the  greater  resistance 
that  the  sinciput  meets  as  it  descends  the  posterior  wall  of  the 
parturient  canal,  which  is  so  much  longer  than  the  anterior  wall. 

IntcDial  Rotation. — This  is  a  well-defined  movement  of  the 
head  whereby  the  occipital  end  turns  to  the  middle  line  anteriorly 
as  it  approaches  the  outlet  of  the  pelvis.  The  result  of  this  change 
is  to  bring  the  anterior  or  long  diameters  of  the  head  into  relation 
with  the  longest  diameter  of  the  outlet — /.  c,  the  conjugate.  The 
movement  varies  in  different  cases  as  regards  its  extent  and  the 
level  at  which  it  occurs,  but  it  probably  always  takes  place  below 
the  level  of  the  ischial  spines.  Various  theories  have  been  ad- 
vanced to  explain  the  reason  for  this  movement.  That  which 
associates  it  with  the  shape  of  the  head  must  be  entirely  discarded. 
Rotation  occurs  in  presentations  other  than  vertex — /.  r.,  face, 
breech,  shoulder,  when  the  relationship  between  fetal  and  mater- 
nal parts  is  very  different  from  that  found  in  normal  vertex  cases. 
So  must  that  which  attributes  the  movement  to  the  influence  of 
the  inner  surface  of  the  bony  canal  on  the  fetal  head,  for  rotation 
occurs  in  breech  and  transverse  cases,  and  in  pelves  so  distorted 
that  the  normal  relationships  are  absent. 

Olshausen  believes  that  internal  rotation  of  the  head  is  merely 
the  result  of  a  movement  of  the  trunk  ;  he  states  that  the  com- 
pression of  the  uterine  wall  on  the  trunk  after  the  escape  of  the 
liquor  amnii  causes  its  rotation,  and  consequently  that  of  the 
head.  This  view  is  entirely  incorrect  because,  clinically,  it  can  be 
demonstrated  that  rotation  does  not  take  place  immediately  after 
the  liquor  amnii  escapes ;  and  that  rotation  of  the  trunk  is  not 
necessarily  followed  by  rotation  of  the  head.  Indeed,  in  Barbour 
and  Webster's  second-stage  case,  in  which  the  head  (O.  L.  A.)  is 
rotated  so  that  the  occiput  is  near  the  front,  lying  low  in  the 
pelvis,  the  trunk  is  so  placed  that  the  back  looks  to  the  front  and 


MECHANISM   OF  LABOR.  211 

left ;  in  other  words,  the  head  has  begun  to  rotate  while  the  trunk 
has  not. 

There  can  be  no  doubt  that  the  chief  factor  in  producing  inter- 
nal rotation  is  the  sacral  segment  of  the  pelvic  floor.  This  is 
made  up  of  the  tissues  posterior  to  the  vaginal  slit,  consisting 
mainly  of  fasciae,  ligaments,  and  muscles,  with  strong  bony  at- 
tachments, and  it  may  be  regarded  as  composed  of  a  right  and  a 
left  half,  each  of  which  slopes  downward  and  inward  from  the  bony 
wall.  As  the  vagina  is  canalized  by  the  advancing  fetus  the  sur- 
rounding tissues  are  stretched,  and  as  they  possess  some  elasticity 
they  exert  a  recoil  action  on  the  presenting  part  of  the  fetus. 
Berry  Hart  states  that  that  part  of  the  presenting  part  which  first 
strikes  a  lateral  half  of  the  sacral  segment  must  be  rotated  by  the 
resiliency  of  the  part  which  is  pressed  against.  In  the  O.  L.  A. 
case  (now  under  consideration)  the  occipital  end  of  the  head 
first  strikes  the  anterior  part  of  the  left  half  of  the  sacral  seg- 
ment, having  a  shorter  vertical  distance  to  travel  than  the  sin- 
cipital portion  of  the  head,  and  is  moved  forward  and  inward. 
When  the  occiput  looks  directly  forward  the  head  lies  symmetri- 
cally in  the  pelvis  and  is  pressed  equally  by  both  halves  of  the 
sacral  segment,  so  that  no  further  rotation  takes  place.  From 
what  has  been  pointed  out  regarding  the  anatomic  conditions  in 
the  pelvis  during  labor,  it  is  very  evident  that  this  adaptation  must 
take  place.  Barbour  and  Webster's  second-stage  section  shows 
clearly  that  the  shape  of  the  vaginal  canal  during  canalization  is 
one  in  which  the  anteroposterior  diameter  is  greater  than  the 
transverse,  so  that  on  cross-section  it  is  somewhat  oval.  A  mass, 
longer  in  one  diameter  than  another,  descending  asymmetrically 
into  relation  with  such  a  passage  must  tend  to  be  rotated  if  the 
wall  is  elastic.  It  is,  indeed,  as  Barbour  states,  largely  a  question 
of  accommodation. 

A  series  of  cross-sections  at  different  levels,  made  by  Zweifel, 
shows  well  the  relative  increase  in  the  conjugate  and  decrease  in 
the  transverse  diameter  as  a  result  of  the  distribution  of  the  soft 
tissues. 

The  direction  of  the  rotation  depends  on  the  part  that  first 
comes  into  contact  with  the  anterior  part  of  the  sacral  segment. 
Dubois  has  experimented  on  the  bodies  of  women  who  have  died 
at  full  term,  and  has  proved  that  by  pushing  the  head  through  the 
pelvis  rotation  occurs  if  the  floor  be  not  injured  by  rupture  or 
overstretching ;  he  found  that  the  occiput  always  turned  forward 
if  it  reached  the  sacral  segment  before  the  sinciput.  Edgar  has 
obtained  similar  results  in  his  experiments. 

As  regards  the  part  played  by  the  body  of  the  fetus  during  the 
descent  of  the  head  to  the  perineum  and  during  the  process  of  in- 
ternal rotation,  the  main  change  is  an  alteration  in  its  attitude 
whereby   it   elongates.     While,  as  has  been  shown,  the  chin  re- 


212      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL    LABOR. 

mains  flexed  on  the  chest  during  this  period,  there  is  an  undoing 
of  the  bent  condition  of  the  back,  so  that  the  breech  and  lower 
limbs  rise  to  a  higher  level.  This  is  the  explanation  of  the  clinical 
fact  that  though  the  head  be  at  the  perineum,  the  breech  of  the 
fetus  may  be  as  high  as  at  the  beginning  of  labor.  Rotation  of 
the  head  is  not  necessarily  accompanied  by  rotation  of  the  body, 
as  Barbour  and  Webster's  sections  show. 

Extc?ision. — This  term  is  applied  to  the  birth  of  the  head  after 
internal  rotation  has  occurred.  The  combined  action  of  the 
uterine  and  accessory  muscles  drives  the  fetus  downward,  the 
head  stretching  the  anterior  part  of  the  sacral  segment  laterally 
as  well  as  in  an  anteroposterior  direction.  The  resistance  of  this 
segment  is  upward  and  a  little  forward.     As  a  result  of  the  action 


Fig.  ii6. — Forward  motion  of  head  during  stage  of  expulsion  under  the  influence  of 
forward  thrust  of  sacrum  and  pelvic  floor  (one-sixth  natural  size). 


of  these  two  forces  the  head  of  the  fetus  is  moved  forward  and 
upward,  the  occiput  sliding  under  the  symphysis,  the  sinciput  and 
then  the  face  passing  over  the  perineum.  During  this  movement 
the  chin  somewhat  leaves  the  chest  of  the  fetus,  though  this  is  not 
so  marked  as  is  generally  believed.  It  is  most  evident  in  primi- 
parje,  and  in  multipara;  with  a  well-preserved  perineum.  The 
latter  feature  also  largely  determines  the  amount  of  upward  gliding 
of  the  occiput  in  front  of  the  symphysis. 

The  birth  of  the  head  is  not  continuous.  It  is  marked  by  ad- 
vance during  the  pains  and  by  recession  between  the  pains  until 
the  posterior  part  of  the  head  is  fairly  in  the  grasp  of  the  vulvar 
girdle.     Thereafter  advance  is  usually  steady  and  rapid. 

External  Rotation  or  Restitution  of  the  Head. — This  term  is 
applied  to  a  movement  of  the  head  that  takes  place  immediately 


MECHANISM   OF  LABOR.  21 3 

after  its  escape  from  the  vulva  or  with  the  recurrence  of  a  pain.  It 
consists  of  a  rotation  whereby  the  occiput  turns  toward  the  side 
to  which  it  was  directed  at  the  beginning  of  labor.  In  the  case 
now  under  consideration  (O.  L.  A.)  it  turns  to  the  left.  This 
movement  though  referred  to  the  head  has  nothing  to  do  with 
the  latter,  being  in  reality  a  change  in  the  body  of  the  fetus,  to 
which  the  head  movement  is  secondary.  By  the  time  the  head 
is  born  the  shoulders  of  the  fetus  have  come  into  relationship 
with  the  sacral  segment  of  the  pelvic  floor.  It  has  already  been 
pointed  out  that  internal  rotation  of  the  head  is  not  necessarily 
accompanied  by  any  corresponding  rotation  of  the  trunk,  at  least 
until  the  former  is  nearly  complete  (shown  by  Barbour  and  Web- 
ster's sections),  so  that  ordinarily  the  long  diameter  passes  through 
the  upper  part  of  the  pelvis  in  an  oblique  diameter  opposite  that 
in  which  lay  the  long  diameter  of  the  head  ;  therefore,  in  the  case 
now  being  considered  (O.  L.  A.),  in  the  left  oblique  diameter. 

Coming  in  contact  with  the  sacral  segment  of  the  floor,  rota- 
tion must  take  place  in  such  a  manner  that  an  accommodation 
of  diameters  is  brought  about.  The  anterior  or  left  shoulder  of 
the  fetus  striking  the  right  half  of  the  sacral  segment  first  is 
rotated  to  the  front.  Very  rarely  in  an  O.  L.  A.  case  may  rota- 
tion of  the  head  to  the  right  be  noted.  The  explanation  is  proba- 
bly due  to  the  shoulders  descending  transversely  or  even  rotating 
somewhat,  so  that  the  bisacromial  measurement  occupies  an  ob- 
lique diameter  opposite  to  that  in  which  it  lay  early  in  labor. 

Under  these  circumstances  it  is  easy  to  understand  how  the 
shoulders  might  be  turned  at  the  pelvic  floor  so  that  the  back  is 
directed  to  the  right,  the  occiput  being  correspondingly  turned.  It 
must  be  remembered  that  cases  in  which  this  abnormal  rotation 
occurs  may  thus  be  wrongly  diagnosed  O.  D.  A.  or  O.  D.  P. 
cases,  in  which,  of  course,  the  normal  rotation  of  the  shoulders 
turns  the  occiput  to  the  right  side. 

Some  authors  hold  that  the  external  rotation  of  the  head  is 
merely  an  undoing  of  the  twisting  of  the  neck  produced  during- 
the  movement  of  internal  rotation.  That  this  may  play  a  part  in 
some  cases  cannot  be  denied,  but  if  it  were  always  the  cause,  ex- 
ternal rotation  should  occur  as  soon  as  the  head  is  born.  In  very 
many  cases  there  is  a  pause  at  this  stage,  the  head  turning  only 
when  pains  drive  the  shoulders  down  into  relationship  with  the 
floor  of  the  pelvis. 

ExpJilsion  of  the  Trunk. — After  the  shoulders  have  rotated,  the 
one  that  is  anterior  moves  under  the  symphysis,  the  posterior 
gliding  forward  over  the  perineum.  The  arms  and  trunk  then 
follow.  The  pelvis  usually  rotates  so  that  its  transverse  diameter 
is  in  line  with  the  anteroposterior  diameter  of  the  outlet ;  when 
the  pelvis  is  small  or  the  outlet  large  it  may  not  fully  rotate  and 
may  be  born  obliquely. 


214      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL   LABOR. 

Mechanism  in  Occipitodextra  Anterior  Cases. — In  O.  D.  A. 

cases  the  mechanism  is  similar  to  that  in  O.  L.  A.  cases,  save  that 
rotation  occurs  in  the  opposite  direction.  Thus,  in  internal  rota- 
tion the  occiput  turns  from  the  right  side  to  the  middle  line,  while 
in  restitution  the  shoulders  turn  so  that  the  back  of  the  fetus 
looks  to  the  right. 

Anomalies  in  0.  L.  A.  and  0.  D.  A.  Mechanisjns. — Very  rarely 
the  above-described  mechanism  may  not  take  place.  This  may 
be  found  where  the  parturient  canal  is  very  large  or  the  fetus  is 
small.  The  head  may  be  pushed  through  with  its  anteroposterior 
diameter  transverse  or  oblique,  internal  rotation  not  taking  place. 

Mechanism  in  Occipitoposterior  Positions. — This  will  be 
considered  on  page  492. 

Head=moulding  and  Head=marking  in  Occipito=anterior 
Cases. — During  normal  labor  the  shape  of  the  fetal  head  is  altered 
by  the  effect  of  pressure,  both  the  bones  and  the  soft  tissues  being 


Fig.  117. — Configuration  of  fetal  head  after  its  delivery  as  a  vertex  presentation. 

affected.  As  the  head  descends  in  the  attitude  of  flexion  it  is 
compressed  at  successive  levels  by  the  stretched  wall  of  the  par- 
turient canal.  This  pressure  is  relieved  only  when  the  head  has 
passed  through  the  vulva.  The  grip  of  the  girdle  of  contact 
varies  in  different  cases,  from  the  suboccipitofrontal  to  the  sub- 
occipitobregmatic  circumference  of  the  fetal  head.  The  effect  is 
shown  in  the  asymmetrical  shape  of  the  head  after  birth.  If  it 
be  compared  with  the  unmoulded  head,  it  is  found  to  be  elongated 
anteroposteriorly,  especially  in  the  line  of  the  maximum  diameter 
of  Budin.  There  is  relative  shortening  of  the  suboccipitofrontal 
and  the  suboccipitobregmatic  diameter.  The  parietal  bone  which 
is  anterior  in  the  pelvis  during  labor,  may  somewhat  override  the 
other.  Thus,  in  O.  L.  A.  cases  the  right  parietal  is  higher  than 
the  other,  while  in  O.  D.  A.  cases  it  is  the  left.  The  reason  of 
this  relationship  is  that  for  a  considerable  time  in  labor  the  anterior 
parietal  bone,  being  opposite  the  anterior  deficiency  in  the  bony 


THIRD   STAGE    OF  LABOR.  21  5 

pelvis,  is  bulged  in  the  direction  of  least  resistance,  while  the  pos- 
terior parietal  bone  is  forced  under  the  other.  After  internal 
rotation  prolonged  compression  of  the  head  at  the  outlet  is  likely 
to  depress  the  frontal  bones  below  the  level  of  the  parietal,  and 
sometimes  the  latter  may  override  the  others.  Very  frequently 
the  supra-occipital  bone  is  somewhat  pressed  under  the  posterior 
edges  of  the  parietals. 

The  soft  tissues  are  altered  as  follows  :  During  labor  that  por- 
tion of  the  scalp  below  and  within  the  girdle  of  compression 
becomes  congested,  darker  in  color,  and  swollen  as  a  result  of 
edema,  blood  being  sometimes  extravasated.  The  elevation  thus 
formed  is  known  as  the  caput  siiccedanciLiii.  Sometimes  it  may 
develop  before  rupture  of  the  membranes,  but  usually  afterward, 
in  the  second  stage.  More  than  one  swelling  is  often  produced. 
The  earliest  is  formed  before  internal  rotation  occurs,  on  that  part 
of  the  head  related  to  the  anterior  deficiency  in  the  bony  pelvis. 
Therefore,  in  O.  L.  A.  cases  it  develops  on  the  upper  posterior  part 
of  the  anterior  or  right  parietal  bone  ;  in  O.  D.  A.  cases  on  the  upper 
posterior  part  of  the  left  parietal  bone.  As  the  head  rotates  to  the 
front,  the  occiput  reaching  the  middle  line,  the  swelling  develops 
toward  the  tip  of  the  occiput.  While  the  head  is  delayed  at  the 
outlet  the  occipital  caput  becomes  larger.  The  earliest-formed 
swelling  is  sometimes  termed  the  primary  caput.  The  last  formed, 
that  over  the  tip  of  the  occiput,  being  the  secondary  caput.  After 
the  birth  of  the  child  a  sulcus  may  sometimes  be  noticed  between 
these,  though  generally  they  form  a  continuous  swelling. 

Great  variations  are  found  in  the  extent  to  which  these  head 
changes  are  produced.  When  the  skull  is  very  small  or  the 
passages  larger  the  asymmetry  may  only  be  slightly  marked,  and 
there  may  scarcely  be  any  overriding  of  the  bones  or  a  visible 
caput  succedaneum.  A  caput  may  be  formed  on  the  vertex  in 
the  first  stage,  especially  if  there  be  premature  rupture  of  the 
membranes  or  if  the  latter  be  abnormally  stretched  and  forced 
through  the  cervix  as  a  pouching  bag,  leading  to  a  diminution  of 
resistance  over  the  lowermost  portion  of  the  scalp.  The  caput 
usually  disappears  within  thirty  hours  of  birth,  while  the  distor- 
tion of  the  bones  also  disappears  to  a  considerable  extent  within 
the  same  period,  though  five  or  six  days  usually  elapse  before 
the  disappearance  is  complete. 

THIRD  STAGE  OF  LABOR. 

Anatomy  and  Physiology. — Uterus. — Following  the  ex- 
pulsion of  the  fetus  and  liquor  amnii,  retraction  takes  place  in  the 
greater  part  of  the  uterine  wall,  which  becomes  thickened  and 
reduced  in  area.  The  stretched  and  thinned  cervix  partly  recovers 
itself,  becoming  thicker  and  shorter.     The  lower  uterine  segment 


2l6      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL    LABOR. 

only  partially  retracts,  and  may  be  folded  on  itself  by  the  pressure 
of  the  upper  segment.  The  most  marked  change  is  in  the  upper 
uterine  segment,  whose  wall  is  everywhere  considerably  thickened 
where  the  placenta  is  not  attached.  At  the  placental  site  its 
thickness  is  only  slightly  increased  because  of  the  mechanical 
obstacle  offered  to  retraction.  (The  same  peculiarity  was  pointed 
out  in  describing  retraction  in   the   uterus  during  labor.)     The 


M 


'  "^r' /^ii'-  ^^^\%' 


WAi^m^ 


Fig.  ii8. — Vertical  mesial  section  of  the  body  in  the  beginning  of  the  third  stage. 
The  body  has  been  frozen  in  the  erect  posture,  causing  exaggerated  anteversion  of  the 
uterus  (Pestalozza)  :  f.  Fundus  ;  p,  placenta  ;  «,  uterine  cavity,  appearing  as  a  slit ;  l.s, 
lower  uterine  segment ;  v,  vagina  ;  u.c,  umbilical  cord  ;  b,  bladder.  The  placenta  is  as 
yet  unseparated.  The  thinnest  part  of  the  wall  of  the  body  of  the  uterus  is  that  to 
which  the  placenta  is  attached.  The  membranes  are  detached  from  the  lower  uterine 
segment. 

placenta  itself,  while  firmly  attached  to  the  uterus,  diminishes 
somewhat  in  superficial  area,  becoming  thickened  and  somewhat 
folded,  and  bulged  at  the  borders.  It  forms  a  mass  that  is  com- 
pletely embraced  b}''  the  retracted  uterine  Avail,  there  being  no 
space  left  in  ntero,  the  amnion-covered  surfaces  being  in  apposi- 
tion. Pestalozza  has  published  frozen  sections  of  women  who 
died  in  the  beginning  of  the  third  stage,  one  being  a  single  and 
the  other  a  twin  pregnancy.     The  various  points  mentioned  are 


THIRD   STAGE    OF  LAIWR. 


217 


therein  well  demonstrated.  In  the  former  the  length  of  the  uterus 
from  the  fundus  to  the  os  externum  measures  nearly  8  in.,  of 
which  two-thirds  were  composed  of  upper  uterine  segment.  The 
anteroposterior  diameter  of  the  latter  measured  4  in.  The  thick- 
ness of  its  retracted  wall  averaged  I  in.  except  where  the  placenta 
was  attached ;  there  it  measured  \  in.  The  membranes  at  this 
time  were  attached  to  the  uterine  wall  save  over  the  area  cor- 


FlG.  119. — Vertical  mesial  section  of  a  woman  who  died  after  the  expulsion  of  twins 
from  the  uterus.  The  uterus  is  retracted  on  the  two  placentae,  but  there  is  no  separa- 
tion of  the  latter  from  the  uterine  wall  (Pestalozza)  :  a,  Upper  placenta;  b,  lower  pla- 
centa; c,  two  umbilical  cords  lying  in  the  cervix  and  vagina;  d,  cervix;  <?,  bladder ; /i 
thickest  retracted  portion  of  the  uterine  wall. 


responding  to  the  greater  part  of  the  lower  uterine  segment  as  it 
e.xisted  in  the  second  stage  of  labor. 

(It  has  been  shown  that  they  begin  to  be  separated^to  form  the 
bag  of  membranes  during  the  first  stage,  and  in  the  second  stage 
are  found  separated  along  an  irregular  line  as  high  or  nearly  as 
high  as  the  retraction  ring).  Over  the  upper  uterine  segment  they 
are  attached,  though  much  crumpled  as  the  result  of  the  reduction 


2l8      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL    LABOR. 

in  size  of  the  area  of  the  uterine  wall.  The  decidua  and  chorion 
are  together  arranged  in  a  series  of  folds,  and  a  similar  change  is 
produced  in  the  amnion,  though  the  latter  is  entirely  independent 
of  the  former  save  where  the  amnion  and  chorion  are  closely 
united.  The  foldings  are  not  uniformly  marked,  being  narrower 
and  more  numerous  in  the  amnion.  The  chorionic  and  decidual 
folds  vary  according  to  the  thickness  of  the  spongy  layer ;  where 
the  latter  is  scanty  very  slight  folding  occurs.  The  independent 
arrangement  of  the  amnion  is  made  possible  by  the  presence  of 
delicate  strands  connecting  the  amniotic  and  chorionic  connective 
tissue  over  a  large  area ;  they  may  be  somewhat  torn  during  re- 
traction. In  some  parts  these  are  absent,  the  amnion  and  chorion 
being  firmly  joined.  The  decidua  and  membranes  thus  form  a 
layer  considerably  thicker  than  is  present  in  pregnancy,  as  a  result 
of  the  changes  due  to  retraction.  The  alteration  in  the  decidua 
is  due  to  the  large  amount  of  reticulated  structure  that  is  present 
at  the  end  of  pregnancy.  Before  labor  its  spaces  are  flattened 
more  or  less  obliquely  or  parallel  to  the  muscular  wall.  During 
retraction  they  become  crumpled  and  irregular. 

The  shape  of  the  uterus  varies  according  to  the  size  of  the 
placenta  and  its  site  of  attachment.  When  it  is  situated  on  the 
anterior  or  posterior  wall,  the  retracted  organ  is  somewhat  \\'ider 
transversely  than  anteroposteriorly.  The  wall  to  which  the 
placenta  is  attached  may  form  a  bulging  that  does  not  exist  on 
the  opposite  wall.  The  anterior  wall  is  wider  than  the  posterior 
when  the  placenta  is  situated  on  it,  and  vice  versa. 

When  the  placenta  is  fundal  the  body  has  a  more  globular 
shape  than  when  it  is  attached  to  the  anterior  or  posterior  wall. 
When  the  placenta  is  praivia,  being  situated  mainly  or  entirel}^  in 
the  lower  uterine  segment,  the  walls  of  the  upper  segment  retract 
more  than  in  normal  cases  ;  they  are  more  thickened  and  form  a 
mass  of  smaller  bulk,  since  they  are  separated  only  by  membranes. 
When  the  woman  lies  in  the  dorsal  position  the  uterus  lies  against 
the  spine,  the  fundus  above  the  umbilicus,  opposite  the  junction  of  the 
third  and  fourth  lumbar  vertebrae,  or  about  6^  in.  above  the  sym- 
physis, on  an  average,  the  bladder  and  rectum  being  empty.  The 
height  varies  normally  considerably — /.  c,  from  14.5  to  17.8  cm. 
(Sf  to  7  in.),  according  to  the  size  of  the  uterus,  the  size  of  the 
placenta,  the  shape  of  the  pelvis,  and  the  condition  of  the  rectum 
and  bladder.  It  may  be  symmetrically  placed  or  may  be  deviated 
to  one  or  the  other  side  ;  in  some  cases  it  may  be  slightly  rotated 
to  one  side  or  the  other  on  its  long  axis.  With  the  hand  its  posi- 
tion may  easily  be  changed.  When  the  woman  sits  or  stands  the 
fundus  falls  forward,  becoming  markedly  anteverted,  and  the  in- 
testines rest  on  its  posterior  surface.  (See  Pestalozza's  section, 
Fig.  119.)  The  consistence  of  the  wall  of  the  retracted  uterus  at 
this  period  is  one  of  firmness,  but  it  has  not  the  hardness  of  the 


THIRD   STAGE    OF  LABOR.  2ig 

empty  contracted  uterus.  It  may  be  dimpled  easily  by  the  press- 
ure of  a  finger. 

Vagina — The  wall  of  the  vagina  is  soft  and  relaxed,  a  certain 
amount  of  retraction  having  taken  place  in  it,  more  marked  in  the 
upper  than  in  the  lower  portion,  and  varying  in  extent  in  different 
cases.  There  is  usually  a  considerable  amount  of  gaping  in  it, 
especially  in  the  lower  part.  The  perineum  and  vulva  have  some- 
what recovered  their  shape  by  retraction  of  the  tissues,  but  they 
are  still  very  lax  and  stretched,  marked  variations  being  found  in 
different  cases.  The  bladder  has  sunk  from  the  position  occupied 
during  the  second  stage  of  labor  and  has  resumed  its  preparturient 
shape,  though  it  lies  at  a  slightly  lower  level.  The  pelvic  peri- 
toneum has  retracted  somewhat  and  has  descended  on  each  side 
where  it  was  elevated  in  pregnancy.  It  is  considerably  wrinkled 
over  the  bladder  and  lower  part  of  the  uterus. 

Changes  During  the  Third  Stage. — The  processes  to  be 
studied  during  this  stage  are  :  i.  Separation  of  the  placenta  and 
membranes.     2.  Expulsion  of  the  placenta. 

Different  views  have  been  current  as  to  the  method  by  which 
the  placenta  is  separated  from  the  uterine  wall  in  normal  labor. 
It  was  formerly  taught  that  partial  separation  took  place  dur- 
ing the  second  stage  as  a  result  of  uterine  retraction,  the  pla- 
centa not  being  able  to  undergo  a  corresponding  change  ;  the 
cyanosis  of  the  head  of  the  fetus  when  delayed  at  the  vulva 
was  thought  to  be  due  to  this.  Frozen  sections  have,  how- 
ever, demonstrated  that  normally  there  is  no  separation  during 
this  stage,  and  that  a  small  amount  of  retraction  in  the  placenta 
takes  place,  accompanying  the  retraction  that  occurs  in  the  upper 
uterine  segment,  though  in  the  latter  it  is  very  much  less  marked 
in  the  placental  part  of  the  wall  than  in  the  non- placental  part. 
The  cyanosis  is  explained  in  some  cases  by  pressure  on  the  cord, 
but  generally  by  the  interference  with  the  circulation  of  maternal 
blood  to  and  from  the  intervillous  spaces  of  the  placenta,  caused 
by  the  retraction  of  the  musculature.  Others  have  held  that 
separation  takes  place  immediately  after  the  escape  of  the  fetus 
and  liquor  amnii,  as  a  result  of  the  shrinkage  in  area  of  the 
uterine  wall  by  retraction,  the  placenta  not  being  able  to  follow, 
the  diminishing  area  being  thus  forced  from  its  attachment.  This 
view  is  denied  by  many  who  hold  that,  while  it  may  apply  to  some 
cases,  it  is  not  to  be  regarded  as  normal. 

Barbour  in  particular  has  shown  that  the  placenta  that  dimin- 
ishes in  area  without  separation  during  the  second  stage  continues 
to  shrink  after  the  escape  of  the  fetus,  following  the  retracting 
uterine  wall  without  separation.  The  area  of  the  placental  attach- 
ment at  the  beginning  of  labor  is  about  35  to  40  sq.  in.  Barbour 
has  measured  it  in  uteri  removed  by  Porro-Caesarean  section  and 
found  it  to  be  14  to  21  sq.  in.     In  two   cases   its   diameters  were 


220      ANATOMY  AND   PHYSIOLOGY  OF  NORMAL    LABOR. 


Fig.  I20. — Vertical  mesial  section  of  uterus  and  contents  removed  after  a  Porro- 
Cassarean  section.  The  cervix  was  divided  below  the  os  internum.  The  uterus  is 
retracted  on  its  contents :  a.  Umbilical  vein  ;  b,  placenta ;  c,  anterior  uterine  wall ;  d, 
posterior  uterine  wall;  c,  membranes  bulging  through  the  cervix.  The  placenta  is 
attached  to  the  posterior  uterine  wall  and  is  not  separated. 


THIRD   STAGE    OF  LABOR.  221 

4  by  \\  in. ;  in  a  third  case  5  by  5I  in.  In  these  cases  there  was 
no  separation  and  the  placenta  was  embraced  by  the  upper  uterine 
segment,  as  has  already  been  described.  Frozen  sections  have 
corroborated  these  findings.  I  have  already  described  those  of 
Pestalozza.  In  Pinard  and  Varnier's  section  of  a  woman  who  died 
after  the  birth  of  triplets,  there  is  only  very  slight  separation  of 
the  lower  edge  of  the  placenta,  the  great  mass  having  diminished 
without  any  separation  ;  in  such  a  case  it  might  be  expected  that 
the  normal  process  should  not  always  be  followed  on  account  of 
the  size  of  the  placenta.  Yet  Pestalozza's  twin  case,  in  which  the 
placenta  was  large,  shows  that  the  lower  edge  is  not  necessarily 
separated. 

Of  the  views  most  prevalent  at  the  present  time  the  following 
may  be  mentioned : 

{a)  Separation  associated  with  the  formation  of  a  retroplacental 


',-^ 


Fig.  121. — The  more  favorable  mechanism  of  expulsion  of  placenta  (Varnier). 

hematoma.  Schultze  advanced  the  view  that  after  the  birth  of 
the  fetus  a  contraction  of  the  uterus  diminishes  the  placental  area, 
so  that  the  central  part  of  the  placenta  is  separated.  Blood  is 
poured  from  the  uterine  sinuses  into  the  space  between  the  pla- 
centa and  uterine  wall,  and,  continuing  to  increase,  causes  the  rest 
of  the  placenta  to  be  separated.  He  holds  that  the  fetal  surface 
of  the  placenta  always  presents  at  the  os  externum,  and  that  a 
certain  amount  of  blood  is  a  necessary  accompaniment  of  pla- 
cental delivery.  Various  modifications  of  this  view  have  been 
advanced. 

Schultze's  view  must  now  be  regarded  as  discredited  as  applied 
to  the  great  majority  of  labors.  Many  specimens  have  shown 
that  the  edge  of  the  placenta  presents  at  the  os  externum  far 
more  frequently  than  the  fetal  surface,  and  that  this  usually  occurs 
without  the  development  of  a  blood-clot ;  the  latter  cannot,  there- 
fore, be   regarded  an   essential   cause.     The  retroplacental  clot  is 


222      ANATOMY  AND   PHYSIOLOGY  OF  NORiVAL   LABOR. 

most  frequent  when  the  placenta  has  had  a  fundal  attachment, 
but  there  is  no  proof  that  it  is  anything  more  than  an  accidental 
accompaniment  of  separation. 

{p)  The  view  which  is  most  in  keeping  with  the  anatomic  and 
clinical  data  at  the  present  time  is  that  of  which  Barbour  has  been 
the  chief  exponent.     This  authority  has  mainly  emphasized  the 


Fig.    122. — The    less   fivorable    of  the    common    methods    of    expulsion    of  placenta 

(Varnier). 

facts  that  the  so-called  cavity  of  the  uterus  at  the  beginning  of 
the  third  stage  is  a  mere  slit ;  that  the  formation  of  a  blood-mass 
between  the  placenta  and  uterine  wall  does  not  generally  occur; 
that  the  retracted  uterine  wall  is  closed  upon  the  placenta,  which 
is  folded  and  diminished  in  area  to  nearly  half  that  which  existed 
at  the  beginning  of  labor  ;  that  this  shrinkage  is  possible  becau.se 


Round  ligament. 
Fallopian  tube. 


Placenta. 


Posterior  uterine  — 
•wall. 


Membranes. 


^^^m- Fallopian  tube. 


Fig.  123. — Transverse  section  of  uterus  removed  by  Porro-Caesarean  section.  Note 
the  retraction  of  the  uterus  on  the  placenta  vi^hich  is  attached  to  the  posterior  uterine 
wall  (Barbour). 


of  the  spongy  nature  of  the  placenta.  As  the  latter  is  compressed 
much  maternal  blood  is  squeezed  out  of  the  intervillous  spaces 
into  the  uterine  vessels,  and  fetal  blood  out  of  the  villi  into  the 
vessels  of  the  cord.  The  reduction  in  size  is  assisted  if  the  child 
is  allowed  to  breathe  several  minutes  before  the  cord  is  cut,  so  as 
to  aspirate  the  circulation  in  the  villi ;  and  afterward,  as  well,  if 


THIKD   STAGE    OF  LABOR.  223 

the  cord  is  cut  without  being  tied  on  the  placental  side,  and  allowed 
to  bleed. 

Beyond  a  certain  point,  however,  the  placenta  cannot  diminish. 
When  contractions  of  the  uterine  muscle  occur,  causing  a  diminu- 
tion in  the  size  of  the  placental  area,  the  placenta,  not  being  able 
to  follow  this  change,  necessarily  becomes  separated.  This  prob- 
ably begins  at  the  lower  margin,  since  this  part  of  the  placenta  is 
subject  to  less  pressure  than  the  rest,  being  opposite  the  lumen 
that  leads  through  the  lower  uterine  segment  and  cervix.  Clin- 
ically this  separation  of  the  lower  margin  may  often  be  made  out. 
There  has  been  some  difference  of  opinion  as  to  whether  entire 
separation  may  be  brought  about  as  a  result  of  contractions  that 
do  not  force  the  placenta  downward,  or  whether,  after  the  separa- 
tion of  the  lower  edge  has  begun,  the  rest  is  separated  by  being 
forced  down.  It  seems  hkely  that  the  downward  direction  of 
lessened  resistance  is  an  important  factor  in  separation.  Were  the 
placenta  surrounded  on  all  sides  by  a  muscle  contracting  with 
equal  force,  it  is  difficult  to  understand  how  any  separation  could 
occur,  owing  to  the  equality  of  the  pressure.  In  the  uterus  the 
placenta  folded  on  itself  is  compressed  during  contractions  above 
and  around,  but  not  below  it.  The  mass  is,  therefore,  forced 
downward  in  the  direction  of  least  resistance,  and  separation  can 
only  occur  first  at  the  lower  margin  when  the  placenta  is  situated 
mainly  on  the  anterior  or  posterior  wall.  Succeeding  contrac- 
tions, by  forcing  the  placenta  still  lower,  cause  a  corresponding 
separation  from  the  uterus,  and  the  process  continues  until  the 
upper  segment  is  empty.  As  has  already  been  pointed  out,  the 
placenta  is  driven  down  edge  first,  folded  and  compressed,  in  the 
manner  described  by  Matthews  Duncan. 

In  the  case  of  a  fundal  insertion  the  mechanism  is  believed  to 
be  somewhat  different.  Here  a  somewhat  central  area  on  the 
fetal  surface  is  opposite  the  canal  of  the  cervix — the  direction  of 
least  resistance — and  separation  occurs  at  this  point  when  contrac- 
tions take  place.  The  placenta  is  thus  driven  down  inverted,  the 
fetal  surface  presenting  in  the  manner  figured  by  Schultze  ;  some- 
times quite  an  amount  of  blood  is  poured  out  above  the  placenta — 
the  so-called  retroplacental  hematoma.  As  this  is  not  always 
present,  it  is  rather  to  be  regarded  as  accidental  than  essential. 

The  expulsion  of  the  placenta  from  the  lower  uterine  segment, 
cervix,  and  vagina  is  brought  about  solely  by  the  accessory 
muscles,  by  gravity,  or  by  a  combination  of  these.  As  women 
are  usually  delivered  in  the  lateral  or  dorsal  position,  gravity  plays 
little  or  no  part,  the  accessory  muscles  being  the  effective  agent. 
If  the  latter  be  inefficient  on  account  of  some  local  or  general 
condition,  the  placenta  may  remain  in  the  lower  segment  and 
cervix,  partly  in  the  cervix  and  partly  in  the  vagina,  or  entirely  in 
the  vagina.     The  membranes  arc  separated  somewhat  as  a  result 


224  CONDUCT  AND   MANAGEMENT  OF  LABOR. 

of  the  crumpling  produced  by  retraction  of  the  uterus  after  the 
birth  of  the  fetus,  but  they  are  mainly  separated  by  being  dragged 
out  after  the  placenta.  Bleeding  does  not  occur  to  any  extent 
from  the  body  of  the  uterus  during  the  normal  third  stage  because 
of  the  retraction  that  greatly  occludes  the  vessels  in  the  wall 
before  separation,  and  because  of  the  further  retraction  and  con- 
traction accompanying  and  following  the  expulsion  of  the  pla- 
centa. 


CHAPTER    III. 
CONDUCT  AND  MANAGEMENT  OF  LABOR. 

Ivying-in  Chamber. — As  the  great  majority  of  labors  take 
place  in  private  houses,  special  precautions  must  be  taken  to  pre- 
pare the  accommodation  necessaiy  for  the  care  of  the  mother  and 
child.  The  smaller  the  dwelling  and  the  more  limited  the  means 
of  the  inmates,  the  more  difficult  it  is  to  attain  to  that  perfection 
in  the  conduct  of  labor  that  is  only  attainable  in  a  well-equipped 
maternity  hospital. 

The  lying-in  chamber  should  be  roomy,  quiet,  and  capable  of 
good  ventilation.  One  with  an  open  fireplace  is,  therefore,  ad- 
visable. Before  the  patient  is  ready  for  it,  all  unnecessary  hangings 
and  furniture  should  be  removed  and  it  should  be  thoroughly 
cleansed.  It  should  not  have  been  occupied  by  a  sick  person 
suffering  from  any  infective  condition.  The  sanitary  arrangements 
of  the  house  should  be  perfect.  If  there  be  a  bath  room  adjacent 
to  the  chamber,  its  plumbing  should  be  in  good  order.  Prepara- 
tions must  be  made  for  obtaining  a  plentiful  supply  of  boiled 
water.  A  couple  of  small  tables  for  holding  instruments,  dress- 
ings, etc.,  are  advisable,  and  a  large  one — /'.  c,  a  kitchen  table, 
should  be  in  readiness  if  certain  manipulations  or  operations  are 
to  be  satisfactorily  carried  out. 

Nurse. — The  selection  of  a  nurse  is  too  often  a  haphazard 
matter.  It  is  generally  left  to  the  patient,  who  thinks  only  of  her 
personal  preference.  Physicians  are  too  lax  in  yielding  to  their 
patients'  wishes  in  this  matter.  The  choice  of  an  obstetric  nurse 
should  be  a  matter  of  the  gravest  responsibility.  Good  character 
and  pleasing  personality  are  important  considerations,  but  if  they 
are  not  combined  with  strict  cleanliness  and  an  aseptic  technic  the 
patient  will  be  subjected  to  great  risks.  The  best  intentions  of 
the  scientific  obstetrician  will  be  in  vain  if  his  nurse  fall  below  the 
level  of  his  ideal  of  work.  She  should  not  have  been  in  attend- 
ance upon  any  case  of  infection  for  at  least  one  week  before  the 
confinement.     During  that  time  she  should  take  daily  baths,  her 


PREPARATION  OF   THE   PATIENT.  22$ 

hair  being  carefully  washed,  and  the  hands  and  arms  being  steril-- 
ized  several  times.  When  she  enters  the  patient's  house  she 
should  wear  freshly  washed  dresses. 

Nurse's  Arrangements. — In  private  practice  it  is  customary 
for  the  nurse  to  attend  to  the  arrangements  that  are  necessary 
preparatory  to  labor.  She  must  see  that  the  following  are  pro- 
vided:  A  supply  of  clean  towels;  a  sterilized  packet  of  a  dozen 
towels  ;  a  couple  of  labor  pads,  made  of  cheese  cloth  filled  with 
absorbent  cotton,  wood-wool,  or  jute,  3  ft.  square  and  3  in.  thick  ; 
two  dozen  vulvar  pads  of  the  same  material,  10  in.  long,  4  wide, 
and  2  thick,  with  end-pieces  that  may  be  fastened  to  the  abdom- 
inal binder ;  a  supply  of  sterilized  pledgets  of  absorbent  cotton ; 
three  or  four  binders  of  unbleached  muslin,  \  yd.  and  \\  yds. 
long ;  two  pieces  of  rubber  sheeting,  3  by  4  ft. ;  a  bedpan  to  be 
used  for  evacuations  ;  another  bedpan  to  be  used  when  the  vulva 
is  washed  or  the  vagina  douched ;  half  a  dozen  fresh-boiled 
sheets ;  several  sterilized  pitchers  and  basins  ;  sterile  glycerin  or 
vaseUn  as  a  lubricant ;  boiled  new  nail  brushes  and  soap ;  a  steril- 
ized fountain  syringe ,  sterilized  safety  pins  and  glass  catheter ; 
steriHzed  cord  ligature  and  dressings  ;  a  piece  of  oil  cloth  or 
sheets  for  the  protection  of  the  floor ;  the  child's  clothing ;  anti- 
septics ordered  by  the  physician. 

Preparation  of  the  Bed. — It  is  best  that  a  narrow  bed  be 
used  for  the  delivery,  the  woman  being  transferred  to  another 
afterward.  The  bed  should  have  a  thick,  firm  mattress.  If  it  be 
not  firm,  boards  may  be  placed  underneath.  Over  it  a  piece  of 
rubber  sheeting  is  placed,  and  this  is  covered  with  a  clean  sheet 
or  piece  of  muslin,  which  is  pinned  to  the  mattress.  On  this  is 
placed  the  labor  pad.  In  place  of  the  latter  folded  sheets  or  a 
sterilized  rubber  pad  may  be  used.  The  upper  bedclothes  should 
be  light  and  the  edges  should  be  fastened  with  safety  pins  or 
stitched  together.  Ordinarily  a  special  bed  cannot  be  obtained. 
Then  it  is  necessary  to  place  a  second  rubber  sheet  over  the  first, 
covered  by  a  sheet.  The  latter  two  are  removed  after  they  are 
soiled  by  the  discharge  of  labor,  the  patient  lying  upon  the  lower 
sheets  after  she  has  been  cleansed. 

Preparation  of  the  Patient. — A  few  days  before  labor  the 
external  genitals  should  be  shaved.  When  the  woman  objects  to 
this  procedure,  she  should  be  informed  of  the  increased  risks  that 
she  incurs.  Frequently  it  is  possible  only  to  cut  the  hair  with 
scissors ;  this  method,  however,  cannot  ensure  such  cleanliness  as 
the  former.  It  is  part  of  a  conscientious  physician's  duty  to  edu- 
cate women  in  this  matter.  When  labor  pains  begin  the  patient 
should  take  a  bath,  unless  she  had  taken  one  a  few  hours  pre- 
viously. The  lower  bowel  must  be  cleaned  out  with  an  enema 
of  soapsuds  and  olive  oil.  The  nurse  should  carefully  wash  the 
external  genitals  with  the  antiseptic  lotions  ordered  by  the  phy- 


226  CONDUCT  AND  MANAGEMENT  OF  LABOR. 

sician,  and  a  pad  soaked  in  the  antiseptic  solution  should  be 
fastened  over  the  vulvar  region.  She  then  puts  on  a  clean  night 
dress  and  stockings,  a  clean  skirt,  and  a  loose  wrapper.  These 
are  worn  as  she  moves  about  during  the  first  stage.  During  the 
second  stage,  as  the  patient  lies  on  the  bed,  it  is  advisable  to  cover 
her  limbs  and  body  in  sterile  cloths,  so  that  only  the  vulva  is 
exposed. 

Physician's  Outfit. — The  obstetrician  should  be  provided 
with  everything  that  is  necessary  for  all  the  conditions  with  which 
he  has  to  deal.  In  private  practice  he  need  not  take  these  to 
every  case  of  labor.  It  is  more  convenient  to  use  an  outfit  for 
the  ordinary  cases,  and  to  have  in  readiness  at  his  home  those 
things  that  are  needed  in  special  cases,  so  that  they  may  be  ob- 
tained at  short  notice.  Various  forms  of  obstetric  bags  are  in 
use.  That  which  the  author  has  found  most  satisfactory  is  the 
form  devised  by  Edgar,  of  New  York.  It  consists  of  two  tra)'s 
made  of  aluminum  or  thin-plated  copper ;  the  larger  fits  in  the 
smaller,  resting  on  a  narrow  shelf  near  the  top.  In  these  trays 
are  all  the  articles  required  at  the  labor.  When  filled  they  are 
placed  in  a  light  outer  covering  fastened  by  straps. 

The  trays  and  their  contents  should  be  sterilized  after  they  are 
used,  so  as  to  be  ready  for  another  case.  It  is  not  necessary  to 
sterilize  them  at  the  patient's  house. 

In  the  lower  tray  is  a  canvas  case,  divided  into  compartments, 
in  which  are  placed  :  A  bottle  of  sterilized  glycerin  ;  a  hypodermic 
needle  with  the  usual  pellets ;  a  case  of  aseptic  ergot  capsules ;  a 
case  of  capsules  of  amyl  nitrite ;  a  bottle  of  sterilized  catgut, 
linen,  or  silkworm-gut  ligatures ;  a  small  case  of  needles  ;  a  pair 
of  scissors  ;  an  eye-dropper ;  a  bottle  containing  an  antiseptic ; 
packets  containing  sterilized  salt  ready  for  making  salt  solution  ; 
dressing  for  the  umbilical  cord. 

The  outer  case  contains  :  A  package  of  Barnes's  and  Cham- 
petier  de  Ribes  bags  ;  a  pair  of  axis-traction  forceps  ;  a  metal  case 
containing  sterilized  cotton  and  antiseptic  gauze  ;  a  metal  case  con- 
taining a  long-curved  glass  uterine  douche  tube,  a  glass  vaginal 
tube,  and  two  glass  vesical  catheters ;  a  package  containing 
sterilized  soft-rubber  and  gum-elastic  bougies  and  catheters  ;  a 
package  containing  a  needleholder,  long  dressing-forceps,  four 
arteiy  forceps  ;  two  pairs  of  boiled  rubber  gloves,  with  a  bottle  of 
sterilized  talc  powder  ;  a  sterilized  rubber  douche  bag  ;  a  sterilized 
apron  ;  a  sterilized  nail  brush  and  nail  cleaner ;  a  bottle  of  anes- 
thetic, wrapped  in  a  sterilized  towel,  may  also  be  kept  in  this  tray. 

This  form  of  bag  is  not  in  general  use,  the  favorite  being  that 
in  which  the  instruments  are  not  kept  sterilized,  but  are  only  pre- 
pared, when  required,  at  the  patient's  house.  The  Edgar  model  is 
a  far  safer  one. 

At  the  bedside  of  the  patient  the  obstetrician  should  wear  a  fresh 


MANAGEMENT   OF   THE   FIRST  STAGE    OF  LABOR.        227 

duck  or  linen  suit,  or  should  divest  himself  of  his  coat  and  waist- 
coat and  put  on  a  linen  gown. 

Management  of  the  First  Stage  of  I,abor. — Obstetri= 
cian's  Duties. — On  arriving  at  the  patient's  house,  it  is  the  physi- 
cian's duty  to  determine  whether  labor  has  actually  begun  and 
how  far  it  has  advanced.  (If  the  woman  be  a  stranger  to  him  he 
must  first  find  out  if  she  is  pregnant.)  The  attitude,  presentation, 
position,  and  vitality  of  the  fetus  should  be  investigated ;  an  effort 
should  also  be  made  to  determine  if  there  is  more  than  one  fetus. 
This  information  should  be  gained  by  questioning  the  patient  and 
the  nurse,  by  watching  the  former  during  pains,  and  by  examining 
her.  In  the  great  majority  of  cases  the  only  examination  necessary 
is  the  abdominal. 

Nothing  is  more  to  be  deprecated  than  the  routine  vaginal  ex- 
amination of  parturient  women  in  obstetric  practice.  It  is  a  fre- 
quent cause  of  infection.  When  it  is  employed,  as  much  care 
should  be  exercised  as  if  a  major  surgical  operation  were  being 
carried  out.  There  should  be  as  much  strictness  as  regards 
cleanliness  in  introducing  the  fingers  into  the  vagina  of  the  par- 
turient woman  as  in  exploring  the  peritoneal  cavity  in  an  abdomi- 
nal section.  In  the  latter  proceeding  every  precaution  is  taken  to 
cleanse  the  skin  of  the  patient  as  well  as  that  of  the  operator's 
hands  and  arms.  In  obstetric  practice  haste  and  carelessness  are 
only  too  frequent.  How  often  is  the  obstetrician  satisfied  with  a 
hurried  application  of  soap  and  water  and  a  momentary  dip  in 
some  antiseptic  solution,  not  of  measured  strength,  but  made  of 
an  unknown  number  of  drops  in  an  unknown  quantity  of  water  ? 
How  frequently  does  he  neglect  to  cleanse  the  external  parts  with 
the  same  thoroughness  that  he  observes  in  preparing  for  surgical 
work  ?  It  matters  not  how  clean  the  fingers  are,  if  the  hair- 
covered  vulva  be  not  attended  to.  Different  workers  have  de- 
monstrated that  it  is  impossible  to  introduce  the  fingers  into  the 
vagina  without  carrying  the  external  contamination.  The  only 
way  in  which  this  risk  can  be  reduced  to  a  minimum  is  by  shaving 
the  vulva  before  every  labor,  cleansing  it  thoroughly  when  labor 
begins,  and  keeping  it  covered  during  labor  with  dressings  soaked 
in  an  antiseptic  solution.  As  regards  the  hands,  in  addition  to 
careful  cleansing  by  one  of  the  best  methods  employed  by  sur- 
geons, boiled  rubber  gloves  should  always  be  used  during  exami- 
nations or  operations.  Recently  a  rubber  dam  containing  a  per- 
foration, to  whose  edges  a  circular  flap  is  attached,  has  been 
introduced  into  practice  for  use  in  examinations.  The  fingers  enter 
the  vagina  through  the  perforation,  the  flap  being  pushed  inward 
and  the  dam  protecting  the  vulva  from  the  hand.  This  is  valuable 
if  it  be  employed  after  external  cleansing  as  above  described.  It 
is  dangerous  if  used  otherwise,  since  micro-organisms  are  certain 


228  CONDUCT  AND   MANAGEMENT   OF  LABOR. 

to  be  carried  into  the  vagina  by  the  rubber  flap  if  they  He  on 
the  vulva. 

When  vaginal  examination  is  necessary,  it  is  best  made  during 
a  pain,  the  effect  of  which  can  thus  be  estimated.  The  condition 
of  the  cervix  and  membranes,  presenting  part,  rectum,  bladder, 
and  soft  passages  may  thus  be  made  out.  (In  all  cases  the  state 
of  the  hard  and  soft  passages  should  have  been  determined  before 
labor  if  the  physician  has  had  the  opportunity  of  examination.) 
The  results  of  examination  should  not  be  communicated  to  the 
patient  if  they  are  unfavorable.  Nothing  should  be  said  to  depress 
her.  If  she  inquires  regarding  the  length  of  labor,  an  indefinite 
answer  should  be  given.  It  may  be  necessary  to  speak  to  her 
husband  or  relatives  as  to  the  conditions  found. 

It  is  important  that  the  arrangements  made  by  the  nurse  should 
be  carefully  inspected  during  this  visit,  and  every  preparation  made 
for  the  conduct  of  the  labor.  Sterilized  dressings  and  instruments 
should  be  placed  where  they  shall  be  ready  for  use.  If  everything 
is  found  satisfactory  and  the  cervix  is  in  an  early  stage  of  dilata- 
tion, the  doctor  may  leave  the  patient  in  the  nurse's  hands,  order- 
ing her  to  inform  him  if  the  membranes  should  rupture,  the  pains 
change  in  character,  or  if  any  complication  should  arise.  It  is 
well  that  he  should  be  present  toward  the  end  of  the  first  stage. 
When  he  returns  to  be  with  the  patient,  it  is  best  that  he  should 
not  remain  with  her  constantly,  but  should  stay  in  another  room, 
visiting  her  from  time  to  time  to  encourage  her,  to  estimate  the 
progress  of  labor,  and  to  observe  the  condition  of  the  maternal 
and  fetal  hearts.  Unnecessary^  persons  must  be  excluded.  As  to 
the  husband,  his  presence  is  sometimes  desirable,  but  generally  he 
should  be  advised  to  keep  away  from  the  lying-in  room. 

Care  of  the  Patient. — The  patient  should  not  go  to  bed  until 
near  the  end  of  the  first  stage,  but  she  should  not  walk  about  too 
freely  before  the  head  is  engaged  lest  a  malpresentation  or  mal- 
position be  induced.  She  should  be  allowed  to  cry  out  during  a 
pain  in  the  first  stage,  and  should  be  told  not  to  press  down. 
She  should  not  take  stimulants,  but  may  be  allowed  to  drink 
fluids.  She  should  urinate  from  time  to  time,  the  amount  being 
noted  to  determine  whether  there  is  any  retention.  Sometimes, 
even  in  the  first  stage,  the  dribbling  of  a  distended  bladder  may 
be  mistaken  for  frequency  of  micturition  ;  the  hypogastric  region 
should  be  occasionally  palpated,  so  that  this  condition  may  be 
diagnosed  if  it  should  occur. 

When  catheterization  is  necessary  the  patient  should  be  placed 
on  the  bed,  with  her  knees  drawn  up  and  separated.  A  clean 
sheet  is  placed  over  her  limbs,  her  clothes  being  drawn  up  under- 
neath. The  vulvar  region  is  exposed  and  the  antiseptic  pad 
removed.  The  hands  of  the  nurse  and  physician  must  then  be 
thoroughly  sterilized  (rubber  gloves  are  safest).     The  labia  and 


MANAGEMENT  OF   THE   SECOND   STAGE.  229 

vestibule  are  sponged  with  the  antiseptic  solution  in  use,  and  a 
boiled  glass  or  metal  catheter  is  held  by  its  outer  end  and  passed 
into  the  bladder.  The  urine  is  caught  in  a  small,  clean  dish  held 
in  front  of  the  patient's  thighs.  The  soft  rubber  catheter  is  em- 
ployed by  many,  but  it  is  objectionable  in  the  hands  of  those 
whose  technic  is  not  perfected,  because  in  introducing  it  into  the 
urethra  it  must  be  held  by  the  fingers  close  to  the  end  that  enters 
the  passage.  Infection,  therefore,  may  be  introduced.  After  the 
catheter  is  withdrawn  the  labia  are  sponged  and  a  fresh  pad  soaked 
in  the  antiseptic  solution  reapplied,  the  patient  again  rising  from 
the  bed. 

Toward  the  end  of  dilatation  her  skirts  should  be  removed 
and  she  should  lie  down  in  bed,  on  her  back  or  side,  as  she 
desires.  Her  night  dress  may  be  folded  or  pinned  high  around 
her  waist,  and  a  folded  sheet  may  be  fastened  around  her  hips  to 
prevent  the  spreading  upward  of  fluids.  In  cases  of  very  tedious 
first  stage,  when  the  patient  is  very  restless,  the  administration  of 
chloral  or  opium  in  a  full  dose  is  often  beneficial  both  in  quieting 
the  patient  and  in  promoting  dilatation  of  the  cervix.  When  dila- 
tation is  well  advanced  and  the  membranes  are  doing  no  good  and 
will  not  rupture,  they  should  be  ruptured  during  a  pain,  with  the 
end  of  a  pair  of  forceps,  a  probe,  or  even  with  the  fingers,  care 
being  taken  not  to  injure  the  scalp  of  the  fetus. 

Manag-ement  of  the  Second  Stage. — The  patient  lies  in 
bed  during  the  second  stage,  on  her  back  or  side,  as  she  desires. 
In  many  hospitals  special  delivery  tables  are  provided.  In  order 
that  she  may  exercise  her  accessory  muscles  to  the  best  advan- 
tage, a  long  towel  or  twisted  sheet  may  be  fastened  to  the  upper 
end  of  the  bed,  so  that  she  may  pull  on  it  during  pains.  She 
should  also  be  encouraged  to  press  her  feet  against  a  firm  object 
placed  against  the  bottom  of  the  bed.  When  uterine  contrac- 
tions recur  she  must  be  told  to  hold  her  breath  and  to  strain 
down.  A  vaginal  examination  may  be  carried  out  early  in  this 
stage  under  careful  precautions,  in  order  to  determine  whether 
there  is  any  abnormality  that  requires  attention.  If  all  is  right  and 
labor  proceeds  satisfactorily  no  further  internal  examination  is 
necessary.  The  physician  may  stay  in  the  lying-in  chamber  or 
elsewhere.  Usually  it  is  best  to  see  her  only  at  intervals,  when 
the  condition  of  the  maternal  and  fetal  hearts  and  the  character 
of  the  pains  must  be  noted.  When  the  head  reaches  the  perineum 
he  should  remain  constantly  at  the  bedside. 

When  the  pains  are  severe  some  relief  may  be  afforded  if  the 
patient  lies  on  one  .side  and  allows  the  nurse  to  press  against  the 
sacrum  during  the  uterine  contraction.  If  they  should  become 
infrequent  or  weak,  the  uterus  may  be  stimulated  by  massaging  it 
through  the  abdominal  wall.  The  patient  often  cries  out  for  an 
anesthetic  during   tlic  pains.     She  should  be  encouraged  to  do 


230  CONDUCT  AND   MANAGEMENT   OF  LABOR. 

without  it  as  long  as  possible.  Generally  it  need  not  be  given 
until  the  perineum  begins  to  be  bulged.  A  few  drops  of  chloro- 
form should  be  placed  on  an  inhaler  as  the  pain  comes  on,  and 
the  inhaler  removed  when  it  passes  off  Great  relief  is  thus  often 
afforded  without  the  inhibition  of  muscular  contractions.  The 
influence  may  be  strengthened  by  the  assurance  of  the  physician. 
Indeed,  the  analgesic  effect  is  often  largely  due  to  suggestion. 
The  quantity  of  the  anesthetic  may  be  increased  as  the  vulva  is 
distended.  Cramps  in  the  muscles  of  the  legs  may  give  the 
woman  distress.  To  give  relief  a  handkerchief  may  be  firmly 
twisted  around  the  affected  part  for  a  few  seconds,  or  strong  con- 
tractions in  an  opposing  group  of  muscles  may  be  made. 

In  this  stage  the  patient  should  not  get  out  of  bed  to  evacuate, 
the  bowel  or  bladder.  The  bedpan  should  be  used.  Special 
attention  must  be  given  to  the  bladder  to  prevent  accumulation 
that  may  dela\'  the  advance  of  the  head.  Frequent  dribbling  may 
be  present  without  e\acuation.  The  urine  may  be  retained  in  the 
part  of  the  bladder  that  rises  above  the  pubes  and  may  cause  a 
small  swelling,  which  may  sometimes  be  sensitive  on  palpation. 
To  draw  off  this  portion  a  long  catheter  is  necessar}-.  When  the 
head  presses  against  the  symphysis  a  soft-rubber  instrument  will 
not  pass  into  the  bladder,  as  a  rule.  It  is,  therefore,  necessary  to 
use  a  hard-rubber  or  a  slightly  curved  metal  catheter.  The  glass 
tube  had  better  not  be  employed  in  this  condition,  as  there  is  a 
risk  of  breaking  it.  It  may  be  used,  however,  to  draw  off  water 
that  may  accumulate  below  the  pelvic  brim. 

Care  of  the  Perineum. — As  the  head  bulges  the  perineum, 
dilating  the  anus,  small  masses  of  feces  may  be  forced  from  the 
latter.  They  should  be  caught  in  pieces  of  cotton  and  the  whole 
perineum  washed  in  antiseptic  lotion. 

The  passage  of  the  head  through  the  vulva  is  a  source  of  great 
risk  to  the  structures  surrounding  the  outlet.  They  are  enor- 
mously stretched  and  frequently  are  lacerated.  The  latter  occur- 
rence is  most  frequent  in  primiparse,  the  most  common  tear  being 
through  the  posterior  commissure.  This  is  lacerated  in  about  70 
per  cent,  of  primiparae.  According  to  Schroeder,  there  is  a  lacera- 
tion of  the  tissues  of  the  perineum  in  34  per  cent,  of  primiparae 
and  9  per  cent,  of  multiparae.  Olshausen,  in  ten  years'  work,  re- 
ported 2 1. 1  per  cent,  of  lacerations  in  primiparse  and  4.7  per  cent, 
in  multiparae.  In  the  primitive  races  this  lesion  is  comparatively 
rare.  The  vaginal  wall  is  usually  the  first  to  tear,  and  the  rent 
passes  backward  toward  the  rectum  in  the  middle  line.  Veiy 
rarely  a  central  perforation  is  produced.  Various  means  may  be 
adopted  to  prevent  laceration.  The  position  of  the  patient  is  im- 
portant. The  risk  to  the  perineum  is  greatest  when  the  thighs 
are  well  flexed  toward  the  abdomen.  The  lithotomy  posture, 
therefore,  is   the  worst  of  all.      The  greatest  relaxation  of  the 


MANAGEMENT  OE   THE   SECOND   STAGE.  23 1 

perineum  is  obtained  by  extending  the  thighs.  If  the  patient  be 
on  her  back  or  side  this  is  easily  managed,  separation  of  the  Hmbs 
being  arranged  by  the  nurse.  The  most  marked  relaxation  may 
be  got  by  placing  the  patient  across  the  bed,  her  buttocks  being 
on  the  edge  and  her  limbs  hanging  down.  The  physician  may 
conveniently  attend  to  the  delivery  by  sitting  on  a  chair  between 
her  legs,  which  are  carefully  covered  in  steriUzed  sheets. 

The  perineum  should  be  stretched  slowly,  and  the  head  should 
not  be  allowed  to  pass  through  the  vulva  too  quickly.  When, 
therefore,  the  pains  are  very  strong  or  the  perineum  not  well 
relaxed,  it  is  necessary  to  hold  the  head  back  in  order  that  sudden 
or  undue  pressure  may  not  be  exerted.  To  effect  this,  Hohl  rec- 
ommends applying  the  thumb  to  the  occiput  under  the  symphysis, 
and  the  first  two  fingers  to  the  part  in  relation  to  the  lower  part 
of  the  posterior  vaginal  wall.  Others  recommend  placing  the 
outspread  fingers  over  the  perineum  (as  the  patient  lies  on  her 
side),  protected  by  a  towel,  so  that  they  may  press  back  the  pre- 
senting part  of  the  head.  At  the  same  time  the  patient  may  be 
told  to  diminish  the  force  with  which  she  bears  down.  Often  she 
is  unable  to  obey,  and  it  may  be  necessary  to  push  the  chloroform 
in  order  to  obtain  the  desired  result. 

The  head  must  pass  through  the  vulva  with  its  smallest  circum- 
ference parallel  to  the  outlet.  Consequently  the  occiput  must 
continue  to  lead  and  extension  must  not  occur  too  rapidly.  This 
may  be  best  ensured  by  Ritgen's  method  of  pressing  on  the  sin- 
ciput through  the  tissues  behind  the  anus,  or  by  introducing  two 
fingers  into  the  rectum  and  pressing  on  it.  Occasionally,  when 
the  biparietal  circumference  is  gripped  by  the  vulva,  such  pressure 
between  pains  may  gradually  force  the  head  safely  onward,  though 
generally  the  woman  may  accomplish  this  herself  by  forcing 
steadily  downward.  Fasbender  controls  the  head  by  applying  the 
index  and  middle  fingers  to  the  occiput  and  thrusting  the  thumb 
into  the  rectum,  against  the  sinciput.  Merkerttschiantz  advocates 
exercising  pressure  on  each  side  of  the  middle  line  during  pains  to 
lessen  the  tension  in  the  central  portion  of  the  perineum.  Lusk, 
in  cases  of  rigid  perineum,  was  accustomed  to  draw  the  chin  down 
by  two  fingers  passed  into  the  rectum  until  the  head  bulged  the 
perineum,  and  then  allowing  it  to  recede,  being  careful  to  discon- 
tinue this  maneuver  during  pains.  In  all  the  manipulations  above 
described  sterilized  rubber  gloves  may  be  worn.  When  it  is  nec- 
essary to  pass  fingers  into  the  rectum  the  glove  should  be  dis- 
carded after  the  maneuver  is  finished. 

When  it  appears  certain,  in  spite  of  the  physician's  efforts,  that 
rupture  is  likely  to  occur,  the  operation  of  episiotomy  may  be  em- 
ployed. This  consists  in  making  a  slight  incision  at  some  distance 
from  the  middle  line  on  each  side,  so  that  the  tissues  may  not  tear 
mcsially  toward  the  anus  ;  in  this  way  the  sphincters  of  the  bowel 


232 


CONDUCT  AND   MANAGEMENT  OF  LABOR. 


are  preserved.  The  chief  resistance  in  the  soft  tissues  of  the  outlet 
is  not  the  vulvar  edge,  as  a  rule,  but  a  ring  about  half  an  inch 
above  this.  The  incisions  should,  therefore,  be  made  mainly 
through  this  part.  They  are  best  made  as  a  pain  is  beginning  or 
passing  off.  A  narrow,  blunt-pointed  bistoury  should  be  intro- 
duced flatwise  between  the  head  and  the  tense  ring,  about  an  inch 
from  the  middle  line  when  the  parts  are  stretched.  It  is  then  held 
parallel  xvith  the  long  axis  of  the  mother's  body,  and  an  incision 
made  three-quarters  of  an  inch  long  and  one-quarter  deep.  The 
outer  end  is  close  to  the  vulvar  margin  but  not  involving  it. 
Scissors  are  employed  by  many  in  performing  episiotomy,  but  they 


Fig.  124. — Method  of  performing  episiotomy  with  scissors  (Bummj. 


are  not  so  satisfactory,  as  they  cut  the  skin  unnecessarily.     After 
deliv^ery  the  raw  surfaces  are  sutured. 

Delivery  of  the  Body. — As  soon  as  the  head  is  born  the  neck- 
should  be  examined  to  find  out  if  the  cord  is  coiled  around  it.  If 
it  is,  an  effort  should  be  made  to  draw  the  loop  down  over  the 
head.  If  this  procedure  fails,  it  may  be  possible  to  slip  it  up 
over  the  shoulders  ;  if  this  does  not  succeed,  it  may  be  divided 
and  the  ends  ligatured  or  held  with  forceps.  Mucus  should  then 
be  cleared  from  the  throat  and  mouth  with  a  fing-er  covered  with 
gauze.  The  nose  and  eyes  should  be  carefully  wiped.  The  head 
is  supported  with  a  hand.  The  birth  of  the  shoulders  is  not  to  be 
hastened  unless  there  is  an  indication. 


MANAGEMENT  OF   THE   SECOND   STAGE.  233 

When  a  pain  recurs  the  face  becomes  congested ;  when  it 
passes  off  the  congestion  diminishes.  If  it  continues  and  asphyxia 
threatens  it  is  well  to  promote  delivery.  This  should  be  accom- 
plished by  pressing  downward  on  the  pelvic  extremity  of  the  fetus 
through  the  fundus  uteri.  This  may  be  done  by  one  hand  of  the 
physician,  or  better  by  an  assistant.  If  the  physician  presses  down 
he  should  put  a  sterilized  towel  on  the  abdominal  wall. 

It  is  necessary  that  the  passage  of  the  shoulders  should  be 
carefully  watched  lest  they  increase  the  laceration  of  the  perineum 
already  produced  or  cause  a  fresh  one.  They  should  rotate  at  the 
pelvic  floor,  so  that  the  biacromial  diameter  is  anteroposterior. 
The  hand  should  carefully  guide  them  in  the  proper  axis  of  the 
outlet.  If  there  is  undue  delay  at  this  period,  and  pressure  from 
above  does  not  bring  about  delivery,  it  is  best  to  work  a  finger 
into  an  axilla,  exercising  cautious  traction  while  the  fundus  is  being 


Fig.  125. — Expulsion  of  shoulders. 

pressed  downward.  The  patient  should  also  press  down  with  all 
her  power.  Hurried  delivery  must  be  avoided.  As  the  child's 
body  is  born  it  should  be  guided  by  the  hands  in  the  axis  of  the 
outlet ;  as  it  descends  the  physician's  hand  or  that  of  an  assistant 
should  hold  the  fundus  firmly  and  follow  it  downward.  The  child 
after  birth  may  be  suspended  by  the  heels  for  a  {&\n  seconds  until 
it  begins  to  cry  freely,  when  it  is  placed  on  its  back,  between  the 
thighs  of  the  mother. 

Ligature  of  the  Cord. — The  cord  should  not  be  ligatured 
immediately  after  delivery  in  normal  cases.  Budin  has  showed 
that  by  waiting  the  child  gains  on  the  average  three  ounces  of 
blood.  This  is  due  to  aspiration  as  the  pulmonary  circulation  is 
established,  and  to  the  pressure  of  the  retracting  and  contracting 
uterus  on  the  placenta.  In  feeble  children  this  gain  may  be  very 
important,  though  in  those  who  are  robust  it  does  not  seem  to 
make  much  difference.     Caviligia  has  shown  that  relaxation  of  the 


234  CONDUCT  AND   MANAGEMENT  OF  LABOR. 

uterus  prevents  this  blood  from  passing  in  any  considerable  amount 
into  the  fetus.  Forcible  manual  compression  of  the  uterus  at  this 
time  should  not  be  made,  as  it  forces  the  blood  into  the  fetus, 
raising  the  pressure  too  rapidly  and  endangering  the  heart. 

Pulsation  in  the  cord  ceases  usually  in  four  or  five  minutes, 
but  may  continue  twice  or  three  times  as  long.  If  ligation  be 
carried  out  after  it  has  ceased,  it  appears  that  the  loss  of  weight  in 
the  child  that  takes  place  normally  in  the  first  few  days  following 
delivery  is  less  in  amount  and  of  shorter  duration  than  where  the 
cord  is  tied  early.  Porak  and  Violet  state  that  such  late  ligation 
is  apt  to  be  followed  by  jaundice  for  a  few  days,  due  to  rapid 
breaking  up  of  red  blood-corpuscles.  This  is  often  absent,  how- 
ever. In  practice  it  is  sufficient  to  wait  until  the  child  has  breathed 
three  or  four  minutes  or  has  cried  vigorously  several  times  before 
ligaturing  the  cord.  When  the  child  is  feeble,  premature,  or  small 
the  cord  should  not  be  tied  until  pulsation  has  ceased  in  it.  In 
cases  where  the  child  does  not  breathe  freely  it  may  be  stimulated, 
while  still  attached  to  the  cord,  by  suspending  it  head  down,  by 
slapping  the  thorax,  blowing  on  the  face,  sprinkling  it  with  cold 
water,  or  employing  Buist's  or  Sylvester's  method  of  artificial  res- 
piration. (See  p.  627.)  When  these  are  not  at  once  satisfactory  the 
cord  must  be  ligatured  and  the  child  removed  for  more  thorough 
manipulations.  In  cases  of  emergency — i.  c,  severe  hemorrhage, 
it  may  be  necessary  to  tie  the  cord  and  remove  the  child  at  once, 
so  that  the  complication  ma)'  be  attended  to.  Care  must  be  taken 
in  applying  the  ligature,  so  that  the  vessels  maybe  firmly  secured, 
and  thorough  asepsis  should  be  observed  lest  infection  follow. 
The  physician  should  take  care  that  no  hernial  protrusion  is  present 
in  the  part  to  be  tied. 

Different  methods  of  ligature  have  been  tried.  These  have 
been  fully  elaborated  by  R.  L.  Dickinson.'  Of  these  he  recom- 
mends the  following  : 

{a)  Ligature  of  Vessels. — With  blunt  scissors  the  junction  of 
the  cord  covering  and  the  skin  is  snipped  with  a  pair  of  blunt 
scissors,  the  cord  itself  being  held  up  by  the  nurse.  The  Whar- 
tonian  jelly  is  then  stripped  outward,  leaving  the  stalk  of  vessels 
bare.  The  latter  is  secured  with  a  catgut  ligature  and  the  vessels 
cut  externall}'.  The  stump  tends  to  roll  inward.  A  sterile  dress- 
ing is  placed  over  the  surface,  and  kept  in  position  by  an  abdomi- 
nal binder. 

(p)  Suture. — The  cord  is  held  up  by  the  nurse  and  the  skin 
near  it  held  between  the  thumb  and  finger.  The  cord  is  then  cut 
away,  the  \'essels  being  caught  in  a  pair  of  forceps.  A  running 
suture  of  catgut  is  then  placed  in  the  raw  tissue,  the  skin  edges 
being  also  secured.  The  suture  may  also  be  passed  before  the 
cord  is  cut  away,  being  tied  afterward. 

-^  Trans.  Aiiter.  Gyn.  Soc,  1S99. 


MANAGEMENT  OF   THE    THIRD   STAGE.  235 

((f)  Pressure. — If  the  cord  be  divided  at  the  skin  retraction  of 
the  vessels  occurs,  and  if  pressure  be  kept  up  with  an  aseptic  pad 
and  binder  or  adhesive  strap  bleeding  ceases  and  healing  takes 
place  satisfactorily.  Adhesive  plaster  is  objectionable  in  that  it 
often  irritates  the  skin. 

Neither  of  these  methods  is  the  one  most  frequently  employed, 
mass  ligature  of  the  cord  being  almost  universally  adopted.  It  is 
satisfactory  if  ligation  be  carefully  carried  out  and  if  strict  asepsis 
be  employed.  The  ligature,  consisting  of  narrow  linen  ribbon  or 
a  strand  of  two  or  three  twisted  linen  threads,  may  be  applied 
about  three-quarters  of  an  inch  from  the  belly,  the  part  to  be  tied 
being  firmly  squeezed  between  the  thumb  and  finger  to  diminish 
the  risk  of  after-loosening  by  shrinkage  of  the  Whartonian  jelly. 
The  cord  may  be  cut  about  a  quarter  of  an  inch  beyond  the 
ligature. 

If  the  end  does  not  bleed  it  may  be  wrapped  in  an  aseptic 
dressing.  Powder  is  not  necessary.  The  maternal  end  of  the 
cord  need  not  be  tied  unless  there  should  be  another  fetus  in  the 
uterus.  The  child  should  next  be  wrapped  in  a  blanket  and 
placed  in  a  warm  place  until  the  necessary  attentions  are  given  the 
mother. 

Management  of  the  Third  Stage. — From  the  time  the 
child  is  born  the  hand  of  an  assistant  should  be  kept  on  the  fundus 
of  the  uterus,  the  patient  lying  on  her  back.  If  it  relaxes  ex- 
cessively, becoming  large  and  indistinct,  it  should  be  massaged 
through  the  abdominal  wall. 

In  describing  the  anatomy  of  this  stage,  attention  has  been 
drawn  to  the  relationships  of  the  uterus  after  the  birth  of  the  child, 
when  it  retracts,  closely  embracing  the  still  unseparated  placenta 
and  membranes.  In  this  state  the  consistence  of  the  wall  varies 
according-  to  whether  there  be  retraction,  contraction,  or  relaxa- 
tion.  These  phases  are  usually  met  with,  though  occasionally  the 
placenta  is  born  immediately  after  the  child.  It  is  very  important 
that  the  physician  should  be  able  to  appreciate  these  variations  by 
abdominal  palpation.  The  length  of  time  required  for  the  de- 
livery of  the  placenta  varies  in  different  cases.  In  a  series  of  cases 
left  to  nature,  delivery  took  place  in  the  first  hour  in  44  per  cent., 
in  the  second  hour  in  25  per  cent.,  in  the  third  in  1 1  per  cent. 
In  the  great  majority  of  instances  the  delay  is  not  in  the  separa- 
tion, but  in  the  expulsion  of  the  placenta,  the  latter  having  passed 
from  the  upper  uterine  segment  into  the  lower  segment  and  cervix, 
or,  it  may  be,  partly  into  the  vagina.  Sometimes  it  may  remain 
entirely  in  the  vagina.  There  is  no  doubt  that  the  recumbent 
position  is  mainly  to  blame  for  this  state  of  matters,  for  it  is  very 
infrequently  found  among  women  who  habitually  adopt  a  sitting 
or  squatting  posture  in  labor. 

It  is  necessary,  therefore,  that  nature  must  be  aided  if  women 


236  CONDUCT  AND  MANAGEMENT  OF  LABOR. 

are  to  be  delivered,  in  the  highest  states  of  civilization,  in  the  re- 
cumbent posture.  But  it  is  of  the  greatest  importance  to  know 
when  and  how  to  give  assistance,  since  there  is  no  sphere  of  ob- 
stetric practice  in  which  there  is  more  need  for  careful  procedure. 
In  the  first  place  it  should  be  remembered  that  nature's  imper- 
fection is  usually  not  in  the  separation  of  the  placenta.  This  process 
takes  place  normally  in  ten  to  thirty  minutes  in  the  great  majority 
of  cases  if  the  uterus  be  allowed  to  act,  It  is,  therefore,  not  nec- 
essary, as  a  rule,  to  squeeze  the  uterus  and  forcibly  separate  the 
placenta  from  it.  Such  a  proceeding  is  very  rarely  required.  If 
the  physician  thinks  that  the  uterine  contractions  are  too  feeble,  it 
is  usually  sufficient  to  rub  the  fundus  through  the  abdominal  wall. 
Nature's  fault  is  in  not  expelling  the  separated  placenta,  and  inter- 
ference should  take  place  when  it  is  entirely  or  partly  out  of  the 
upper  uterine  segment,  lying  inert  in  the  lower  passages.  The 
determination  of  this  period  depends  upon  accuracy  in  diagnosis, 
and  this  is  obtained  only  when  the  anatomic  relationships  are  well 
known.  These  have  already  been  carefully  described.  In  almost 
every  case  abdominal  examination  alone  suffices  to  make  out  the 
conditions.  When  the  upper  segment  is  empty  and  contracted,  it 
is  much  harder  and  its  area  smaller  than  when  the  placenta  is  still 
attached,  and  it  is  often  more  mobile.  The  fundus  may  be  as  high, 
however,  if  the  placenta  has  not  descended  well  into  the  vagina. 
The  difference  between  these  two  conditions  is  very  often  over- 
looked by  careless  clinical  observers.  It  is  when  the  placenta  is 
only  partly  expelled  from  the  upper  segment,  or  the  latter  is 
somewhat  distended  with  blood-clot,  that  the  exact  state  is  diffi- 
cult to  determine.  On  abdominal  examination  a  bulging  may 
usually  be  noted  over  the  pubes,  due  to  the  distended  lower 
uterine  segment ;  frequently  vaginal  examination  is  necessary  to 
make  out  the  exact  condition.  When  this  is  made  and  the  pla- 
centa lies  below  the  upper  uterine  segment,  it  is  generally  folded, 
or  sometimes  inverted,  forming  a  large  mass  at  the  level  of  or 
below  the  lower  uterine  segment.  An  old-fashioned  method  of 
obtaining  expulsion  in  this  condition  was  to  make  the  woman 
sneeze  hard  by  giving  her  snuff,  thus  causing  the  placenta  to  be 
forced  from  the  vagina.  At  the  present  time  pressure  through  the 
abdominal  wall  is  the  favorite  means. 

The  upper  segment  is  grasped  anteroposteriorly  through  the 
abdominal  wall,  between  the  thumb  and  fingers  of  one  hand  (both 
hands  may  also  be  employed),  and  is  pressed  steadily  downward 
into  the  pelvis  in  the  axis  of  the  inlet,  care  being  taken  that  the 
bladder  is  empty.  The  placenta  slides  gradually  out  of  the 
vagina,  except  occasionally,  when  it  may  be  partially  adherent  in 
the  uterus  or  firmly  gripped  by  the  latter.  As  it  emerges  from 
the  vulva  the  blood  that  escapes  may  be  caught  in  a  sterilized 
dish  placed  under  the  thighs  or  may  be  absorbed  in  sterile  towels. 


MANAGEMENT  OF  THE    THIRD  STAGE. 


237 


The  placenta  is  held  in  the  hand  and  generally  pulled  outward. 
The  membranes  usually  follow  easily,  but  if  they  do  not  the 
placenta  may  be  rotated  slowly  two  or  three  times,  so  that  they 
become  twisted  into  a  rope.  Slight  adhesions  of  the  membranes 
may  in  this  way  be  separated.  Excessive  twisting  may  cause 
them  to  be  broken.  When  they  do  not  come  away  easily  it  is 
best  to  pass  two  fingers  along  the  twisted  mass,  separating  it 
where  it  is  held. 

In  cases  where  the  delay  in  the  delivery  of  the  placenta  is  due 
to  its  non-separation  or  to  its  retention  in  the  upper  uterine  seg- 
ment, massage  of  the  uterus  through  the  abdominal  wall  must  be 
carried  out.  If  this  is  inefficacious  and  half  an  hour  has  elapsed 
after  labor  the  following  manipulation  should  be  employed :  The 


Fig.  126. — Rotation  of  the  placenta  twisting  the  membranes  into  a  rope  (Bumm). 

uterus  must  be  grasped  anteroposteriorly  with  one  or  both  hands 
(the  bimanual  grasp  is  the  better,  the  thumbs  being  placed  behind 
the  fundus  side  by  side),  and  as  a  contraction  is  felt  should  be 
firmly  but  not  forcibly  compressed  in  order  to  separate  the  pla- 
centa and  squeeze  it  into  the  cervix  and  vagina. 

As  it  passes  downward  the  uterine  body  is  felt  to  grow  smaller. 
It  is  then  pushed  downward  in  the  axis  of  the  pelvic  brim  so  as  to 
further  expel  the  placenta.  This  manipulation  is  generally  known 
as  "  Crede's  method,"  so  named  after  the  Leipzig  professor,  who 
recommended  it  first  in  1853.  There  is  no  doubt  that  the  very 
same  procedure  had  been  previously  long  practised  and  advocated 
in  the  Dublin  School  of  Midwifery.  Jellett  has  clearly  established 
this  fact,  and  has  proved  that  Irish  writers  described  it  in  the  latter 
part   of  the   eighteenth   century.     The  terms  have  been  loosely 


238 


CONDUCT  AND   MANAGEMENT   OF  LABOR. 


applied,  and  there  are  differences  of  opinion  as  to  what  is  exactly 
implied  by  the  Crede  and  Dublin  methods.  A  careful  study  of 
the  literature  of  the  subject  proves  that  terms  have  been  applied 
to  cases  in  which  the  placenta  is  forcibly  separated  and  pushed 
downward  by  compression  and  downward  pressure  of  the  uterus, 
and  to  those  in  which  the  separated  placenta  is  expelled  either 
from  the  uterus  or  lower  genital  canal  especially  by  downward 
pressure  of  the  uterus. 

Great  care  must  be  observed  in  usino;  the  Dublin  or  the  Crede 


Fig,  127. — Crede's  method  of  expressing  the  placenta,  showing  also  episiotomy  incisions 
(photographed  from  nature;   Dickinson). 


method.  The  wall  of  the  uterus  or  the  appendages  may  be  in- 
jured, the  placenta  may  be  torn,  part  being  left  in  the  uterus,  or 
the  inner  surface  of  the  latter  may  be  much  lacerated.  These 
evils  are  most  apt  to  arise  when  strong  efforts  are  made  to  force 
out  a  placenta  that  is  firmly  adherent.  The  method  is,  therefore, 
never  to  be  employed  when  this  complication  exists.  In  this  cir- 
cumstance the  placenta  must  be  removed  by  the  introduction  of  a 
hand  into  the  uterus.  Under  ordinary  conditions  the  Dublin  or 
the  Ci'ede  method  is  not  to  be  employed  until  twenty  to  thirty 


IMMEDIATE   AFTER-DUTIES.  239 

minutes  have  elapsed  after  the  birth  of  the  child.  Only  when 
marked  hemorrhage  is  taking  place  from  the  uterus  must  it  be 
used  earlier  to  hasten  the  emptying  of  the  organ. 

Ergot  is  rarely  necessary.  It  should  not  be  given  before  the 
uterus  is  empty  both  of  the  fetus  and  after-birth,  as  it  may  cause 
such  contraction  upon  the  uterine  contents  as  will  lead  to  difficulty 
in  delivery.  It  is  used  by  many  when  the  uterus  tends  to  relax 
unduly  or  to  bleed  after  the  third  stage.  When  rapid  action  is 
needed  an  aseptic  preparation  should  be  injected  into  the  buttock 
muscles ;  otherwise,  it  may  be  given  by  the  mouth.  Careful 
massage  of  the  fundus  and  the  use  of  a  hot  intra-uterine  douche 
reduce  to  a  minimum  the  necessity  for  the  administration  of  ergot. 

Immediate  After-duties. — After  the  placenta  and  mem- 
branes are  born  they  should  be  carefully  examined.  This  is  most 
satisfactorily  accomplished  by  placing  them  in  a  large  dish  of 
water.  The  maternal  surface  of  the  placenta  must  be  studied  to 
find  out  whether  any  part  has  been  left  in  the  uterus.  The  mem- 
branes and  the  hole  in  them  must  be  carefully  investigated  to 
determine  whether  any  portion  has  been  retained  ;  it  is  easy  to 
decide  when  a  large  piece  has  been  torn  off,  but  impossible  to  be 
accurate  regarding  a  small  piece.  Any  deficiency  in  the  placenta 
demands  an  exploration  of  the  uterine  cavity.  This  rule  holds 
good  with  regard  to  the  membranes  only  when  a  large  portion 
has  been  left ;  small  pieces  of  membranes  are  gradually  dis- 
charged in  the  lochia.  A  distinct  gap  in  the  membranes  lateral 
to  the  normal  opening  should  suggest  the  possibility  of  a  retained 
succenturiate  placental  lobe,  and  warrants  immediate  exploration 
of  the  uterine  cavity. 

The  fundus  of  the  uterus  should  be  frequently  examined  during 
the  half-hour  following  the  third  stage  to  see  that  the  wall  is  not 
relaxed,  and  the  massage  should  be  carried  out,  if  necessary. 
Douching  of  the  genital  tract  is  not  necessary  in  the  great  major- 
ity of  cases.  When  there  is  a  tendency  to  the  accumulation  of 
blood-clots  in  the  vagina,  hot  sterile  normal  salt  solution  may  be 
used.  Antiseptic  solutions  are  only  to  be  employed  when  local 
infection  exists  before  labor  or  when  the  patient  is  subjected  to 
the  risk  of  infection  during  labor. 

Lacerations  of  the  genital  tract  that  require  to  be  sutured 
should  be  attended  to  after  the  delivery  of  the  placenta.  Follow- 
ing labor  the  soiled  skin  of  the  mother  should  be  bathed  in  an 
antiseptic  solution  and  the  blood-stained  clothes  removed.  She 
may  be  removed  to  a  clean  bed  if  there  be  one  in  readiness.  The 
vulva  should  then  be  covered  with  a  dry  aseptic  pad  or  one  moist- 
ened in  an  antiseptic,  which  may  be  attached  to  the  binder.  An 
abdominal  binder  adds  to  the  comfort  of  the  woman  in  most 
cases.  It  may  be  made  of  linen  or,  better,  of  unbleached  muslin, 
and  should  extend  from  just  below  the  great  trochanters  to  near 


240  ASEPSIS  AND  ANTISEPSIS  IN   OBSTETRICS. 

the  sternum.  It  should  surround  the  body,  one  edge  sHghtly 
overlapping  the  other,  and  should  be  fastened  with  safety  pins, 
tightly  around  the  pelvis,  loosely  above.  The  binder  may  be 
worn  a  week  or  two.  If  there  be  anxiety  as  to  undue  relaxation 
of  the  uterus,  three  closely  folded  towels  may  be  placed  under 
the  binder,  one  on  each  side  and  one  above  the  uterus.  These  act 
as  a  mechanical  stimulus  to  the  uterine  muscle.  Under  the  cloth 
on  which  the  patient  lies  the  rubber  sheet  should  be  left  five  or  six 
days.  Over  this  linen  draw-sheets  may  be  used,  and  above  this, 
if  necessar>%  a  series  of  prepared  aseptic  pads. 

The  general  state  of  the  mother  is  carefully  examined,  her 
pulse  rate  noted,  and  the  condition  of  the  uterus  determined  before 
the  physician  leaves  the  house.  In  ordinary  cases  he  is  free  to  go 
away  about  half  an  hour  after  her  toilet  is  completed.  He  in- 
structs the  nurse  to  inform  him  if  the  woman  should  complain  of 
severe  pain,  chills,  or  faintness  ;  if  marked  relaxation  of  the 
uterus  or  hemorrhage  should  occur;  if  the  pulse  should  become 
rapid  or  feeble. 


CHAPTER   IV. 

ASEPSIS  AND  ANTISEPSIS  IN  OBSTETRICS. 

In  1847  Ignatius  Semmelweiss,  by  insisting  that  the  students 
in  his  obstetric  clinic  should  wash  their  hands  carefulh-  in  chlorin 
water  before  examining  patients,  reduced  the  death  rate  due  to 
puerperal  fever  from  10  to  less  than  2  per  cent.  The  medical 
world  paid  no  attention  to  his  results  save  to  scoff  at  them.  In 
1867  Lister  published  his  observations  regarding  the  part  played 
by  micro-organisms  in  causing  wound  infection  and  the  method 
of  preventing  this  by  antiseptic  agents.  Very  soon  the  antiseptic 
method  in  surgery  became  established.  About  1870  antiseptics 
were  introduced  into  obstetric  work  by  Stadfeldt,  of  Denmark, 
and  Bischoff,  of  Switzerland. 

During  the  last  thirty  years,  as  the  knowledge  of  bacteriology 
has  increased,  the  role  played  by  antiseptics  in  surgical  work  has 
become  greatly  restricted,  asepsis  being  obtained  largely  by  other 
means.  As  a  result  of  the  continued  introduction  of  scientific 
principles  estabhshed  mainly  by  surgeons  and  bacteriologists, 
there  has  been  an  enormous  reduction  of  Avound  infections  in 
surgical  work  and  a  corresponding  diminution  in  deaths  due  to 
sepsis. 

In  obstetric  practice  there  has  been  no  such  marked  progress. 
(See  Chapter  on  Puerperal  Sepsis.)  The  vital  statistics  of  many 
civilized   countries   still  show  a  lamentably   high   mortality   due 


HAND-CLEANSING.  24I 

to  puerperal  infection,  and  tJiis  hifection,  it  is  safe  to  say,  is 
almost  entirely  avoidable,  bei)ig  due  to  carelessness  and  ignorance. 
The  death  rate  does  not,  however,  represent  the  extent  of  in- 
fections in  obstetric  work.  There  is  a  much  larger  percentage 
of  cases  in  which  death  does  not  take  place,  but  in  which  the 
health  of  women  is  injured  and  various  disorders  established, 
of  every  degree  of  gravity.  There  has  been  widespread  neglect 
among  medical  practitioners  to  apply  the  principles  of  bacteri- 
ology and  the  practice  of  strict  surgical  technic  in  their  work. 
This  neglect,  in  the  hght  of  modern  knowledge,  deserves  only 
to  be  branded  as  culpable  and  criminal.  There  may  be  some 
excuse  for  an  ignorant  midwife.  The  neglectful  physician  de- 
serves only  the  severest  condemnation.  Labor  is  a  natural  proc- 
ess and  has  a  low  mortality  under  natural  conditions  ;  but  in  the 
artificial  conditions  of  civilization  and  those  introduced  by  the 
practices  of  the  midwife  and  accoucheur  it  has  been  greatly  com- 
plicated, and  the  dangers  accompanying  it  enormously  increased. 
Obstetric  practice  will  never  achieve  what  surgery  has  done  until 
every  parturient  woman  is  treated  as  the  modern  scientific  surgeon 
deals  with  his  operative  cases.  One  aim  must  be  kept  in  mind,  to 
handle  every  case  so  that  all  raw  or  damaged  tissues  should  be 
kept  aseptic  until  healing  is  complete. 

Infection  may  take  place  in  various  ways  :  i.  By  the  hands  of 
the  obstetrician,  his  assistants,  or  nurses.  2.  By  means  of  instru- 
ments, apparatus,  or  other  paraphernalia.  3.  As  a  result  of  non- 
cleansing  or  imperfect  cleansing  of  the  patient.  4.  By  means  of 
the  air. 

The  attainment  of  an  aseptic  technic  is  only  possible  by  con- 
tinued thought  and  practice  and  by  strict  attention  to  details.  Par- 
tial knowledge  is  as  dangerous  as  ignorance.  Those  who  trust  to 
antiseptics  to  obtain  asepsis  are  most  apt  to  fall  into  error.  Many 
obstetricians  think  that  they  satisfy  all  requirements  if  they  dip 
their  fingers  for  a  io.^  moments  into  water  containing  a  few  drops 
of  carbolic  acid,  corrosive  sublimate,  or  some  other  antiseptic. 
Others  think  that  any  procedure  may  be  carried  out  during  labor 
so  long  as  the  vagina  is  douched  with  an  antiseptic  solution  at 
the  end  of  the  third  stage.  Others  think  that  instruments  and 
ligatures  are  rendered  sterile  by  being  dipped  in  boiling  water  a 
minute  or  two.  Such  mistakes  as  these  can  only  be  prevented  by 
a  careful  study  of  bacteria  and  their  properties,  of  antiseptics  and 
their  modes  of  action  and  limitations,  and  of  the  methods  of  ster- 
ilization. In  describing  the  management  of  labor  I  have  referred 
to  the  duties  of  the  accoucheur  and  his  assistants.  (See  p.  227.) 
It  is  here  necessary  to  give  special  attention  to  some  details  of 
technic. 

Hand-cleansing. — The  hands  and  forearms  of  those  who 
may  touch  the  genitalia  of  the  parturient  woman  or  articles  that 
10 


242  ASEPSIS  AND   ANTISEPSIS  IN   OBSTETPICS. 

may  be  brought  into  contact  with  them  must  be  carefully  cleansed. 
The  arms  should  be  bared  well  above  the  elbows,  and  the  hands 
and  forearms  thoroughly  scrubbed  in  hot  water,  soap,  and  turpen- 
tine with  a  stiff  nail  brush  for  six  minutes.  The  nails  should  be 
clipped  short,  and  cleansed  with  a  cleaner.  The  skin  should  then 
be  well  washed  off  in  clean  water  and  dried  on  a  sterile  towel. 
This  mechanical  process  is  very  important  and  should  not  be 
hastened.  It  is  often  very  hurriedly  carried  out.  This  can  only 
be  prevented  by  the  use  of  a  watch  or  clock  to  time  the  procedure. 
Thereafter,  cleansing  is  usually  completed  by  washing  in  antiseptic 
solutions,  many  of  which  are  in  use — /.  c,  carboHc  acid,  lysol, 
creolin,  mercuric  chlorid  or  iodid,  alcohol,  permanganate  of  potash, 
and  oxalic  acid,  etc.  (Details  as  to  the  use  of  these  are  given  in 
surgical  works.)  Regarding  these  chemicals,  it  has  been  clearly 
demonstrated  that  they  are  incapable  of  rendering  the  skin  abso- 
lutely sterile.  The  stronger  the  solutions  and  the  greater  the  time 
of  their  application  the  nearer  is  the  approach  to  perfect  steriliza- 
tion. The  strength  of  solution  must  be  regulated  by  its  destructive 
action  on  the  arm  and  hand,  and  the  period  of  application  by 
considerations  of  practicability.  The  ideal  chemical  antiseptic  in 
skin  sterilization  is  one  that  can  penetrate  the  hair  follicles  and 
glands  of  the  skin,  destroying  micro-organisms  in  a  very  short 
space  of  time  w'ithout  injuring  the  skin.  The  nearest  approach  to 
such  a  preparation  the  author  has  found  in  crenasol.  This  prepa- 
ration is  pure  creolin  minus  soda.  It  has  an  oily  consistence  and 
penetrates  the  skin  well.  Bruere,  of  Montreal,  has  shown  that  it 
is  destructive  to  the  pathogenic  micro-organisms  in  two  minutes. 
It  should  be  applied  to  the  skin  after  the  latter  has  been  well 
scrubbed  and  dried,  and  well  rubbed  in.  It  should  then  be 
washed  off  in  sterile  water  or  sterile  salt  solution.  The  appli- 
cation causes  reddening  and  some  smarting,  but  these  soon  dis- 
appear. The  author  has  not  known  it  to  cause  any  serious  skin 
disorder.  But  whatever  be  the  method  adopted,  the  author 
regards  it  as  only  preparatoiy  to  the  wearing  of  rubber  gloves. 
He  believes  that  these  are  essential  to  ensure  perfectly  sterile 
hands.  They  may  be  used  whenever  it  is  necessary  to  make 
vaginal  examinations  or  to  carry  out  manipulations.  They  are 
sterilized  by  being  boiled  for  eight  minutes,  wrapped  in  a  cloth,  sO' 
as  to  be  protected  from  touching  the  metal  dish.  They  should 
then  be  dried  on  a  sterile  towel.  In  order  that  they  may  easily 
be  slipped  on  the  hands,  the  latter  should  be  covered  with  steril- 
ized talc  powder.  If  the  gloves  be  made  of  rubber  of  medium 
thickness,  the  tactile  sense  is  not  interfered  with.  Indeed,  after  a 
little  practice  one  learns  to  disregard  the  membrane.  The  gloves 
should  protect  the  arm  for  three  or  four  inches  above  the  wrist. 
In  all  cases  in  which  internal  manipulations  are  to  be  employed, 
the  wrist  of  the  glove  should  cover  the  sleeve  of  a  sterile  gown. 


INSTRUMENTS,    APPARATUS,    DRESSINGS,    ETC.  243 

The  best-fitting  glove  is  one  made  on  a  model  shaped  like  the 
hand. 

Many  surgeons  merely  scrub  their  hands  in  soap  and  water 
before  putting  on  the  gloves.  The  author  believes  that  the  addi- 
tional application  of  chemicals  as  above  described  is  advisable,  as 
there  is  much  less  risk  of  infecting  the  patient  if  the  glove  should 
tear  during  manipulations.  Of  course,  if  a  glove  be  torn,  a  fresh 
one  should  at  once  replace  it.  Rents  may  easily  be  repaired,  so 
that  gloves  may  be  made  to  last  several  weeks.  Every  assistant 
and  nurse  who  may  touch  the  genitalia,  or  handle  anything  that 
comes  in  contact  either  with  the  accoucheur's  hands  or  with  the 
genitalia,  should  also  wear  gloves.  Once  clean,  they  should  re- 
main so  as  long  as  they  are  needed  in  the  manipulations.  The 
most  glaring  faults  are  often  committed  by  neglect  of  this  rule. 
Thus,  the  nurse  may  have  cleansed  her  hands  in  order  to  take 
charge  of  the  dressings,  and  in  the  intervals  of  waiting  she  may 
touch  an  unsterilized  bottle  or  adjust  her  dress.  She  may  sud- 
denly catch  an  arm  or  leg  of  the  patient  which  has  broken  loose, 
and  return  to  her  work,  forgetting  that  she  is  contaminated.  Or 
she  may  carelessly  drag  her  dressings  or  ligatures  across  her 
dress  or  some  other  unsterilized  object.  It  is  essential  that  the 
keenest  attention  be  given  to  the  smallest  details  if  perfection  in 
technic  is  to  be  attained. 

In  introducing  the  gloved  fingers  into  the  genital  tract,  it  is 
sufficient  to  wet  them  in  sterile  water  or  salt  solution.  If  the 
whole  hand  is  to  be  introduced,  it  is  best  to  use  a  little  glycerin, 
weak  lysol  or  creolin  solution  (i  :  200)  as  a  lubricant.  Vaselin  is 
said  to  injure  the  rubber  and  should  not  be  used. 

Instruments,  Apparatus,  Dressings,  etc. — {a)  Instru= 
ments — Instruments  should  be  as  simple  as  possible  so  as  to 
afford  no  gathering-place  for  microbes,  and  should  be  made 
entirely  of  metal  when  possible,  all  locks  being  separable.  They 
should  be  kept  carefully  scrubbed  and  polished.  They  may  be 
sterilized  immediately  after  use  and  kept  always  in  readiness, 
wrapped  in  sterile  cloths,  or  may  be  sterilized  at  the  time  they 
are  required.  They  are  best  sterilized  by  moist  steam  or  boil- 
ing. If  the  former  be  used  a  special  steriHzer  is  necessary. 
Exposure  to  steam  under  pressure  at  120°  to  130°  C.  for 
half  an  hour  is  effective.  Boiling  is  a  quicker  and  simpler 
method.  If  the  water  contain  i  per  cent,  of  pure  sodium  car- 
bonate or  bicarbonate  and  about  the  same  amount  of  salt,  the 
instruments  need  be  boiled  only  five  minutes,  all  microbes  and 
spores  being  destroyed  in  that  period.  After  sterilization  they  may 
be  placed  in  a  dry  sterile  dish  or  in  sterile  water. 

ib)  Apparatus. — All  pitchers,  basins,  glass  or  metal  douche 
tubes,  etc.,  that  may  be  used  should  be  sterilized,  if  possible  in  a. steam 
.sterilizer.      In   private  houses  they  may  be  boiled  in  a  washboiler 


244  ASEPSIS  AND   ANTISEPSIS  IN   OBSTETRICS. 

containing  the  soda-salt  solution.  If  this  is  impossible,  the  small 
articles  should  be  boiled  and  the  large  ones  should  be  thoroughly 
scrubbed  in  i  :  500  chinosol,in  a  solution  of  formalin  (ji  to  i  pint), 
or  in  pure  creolin  or  crenasol. 

(t)  Qauze,  Cotton=wool,  Towels,  Sheets,  etc. — Plain  gauze, 
wool,  towels,  and  sheets  should  be  sterilized  in  the  steam  sterilizer 
in  packets  that  should  not  be  opened  until  required.  In  places 
where  this  cannot  be  carried  out,  they  may  be  heated  for  three 
hours  on  three  succeeding  days  in  the  oven  of  a  cooking-range  at 
a  temperature  of  148°  C.  (300°  F.)  or  more,  a  thermometer  being- 
used  to  ensure  the  proper  deviation.  Such  articles  are  penetrated 
very  slowly  by  dry  heat,  and  the  moist-heat  process  is  more  re- 
liable. Boiling  is  more  satisfactory  than  the  diy  process  if  the 
articles  can  be  afterward  dried. 

Cleansing  of  the  Patient. — A  few  days  previous  to  the 
onset  of  the  labor  the  nurse  should  shave  the  woman's  external 
genitals.  (If  this  be  not  allowed,  the  hair  should  be  clipped 
closely.)  Every  day  thereafter  the  vulva  should  be  well  washed 
in  soap  and  water.  At  the  onset  of  labor,  after  the  bowels  have 
been  moved  by  an  enema,  the  external  parts  should  be  washed  in 
alcohol  and  then  in  one  or  other  of  the  following  solutions — 
chinosol  (i  :  1000),  formalin  (30  drops  to  a  pint  of  water),  lysol  or 
creolin  (i  :  100) — fi\'e  minutes.  Then  a  pad  soaked  in  one  of  these 
solutions  should  be  applied  to  the  vulva  and  kept  in  position  by  a 
T-bandage  during  the  progress  of  labor.  Douching  of  the  vagina 
at  this  time  is  not  necessaiy  unless  there  is  some  definite  infective 
process  that  requires  to  be  treated. 

During  the  course  of  labor,  whenever  the  patient  urinates  or 
defecates,  the  vulva  and  perineum  should  be  carefully  sponged 
with  one  of  the  above  lotions  and  the  pad  reapplied.  If  important 
manipulations  are  to  be  carried  out  in  the  genital  tract — /.  r.,  turn- 
ing, application  of  forceps,  etc.,  the  patient  must  be  placed  in  the 
lithotomy  position  on  the  edge  of  the  bed  or  on  a  suitable  table, 
and  the  external  genitals  and  surrounding  skin  cleansed  as  if  some 
surgical  operation  were  to  be  carried  out.  The  vagina  need  only 
be  washed  out  with  normal  salt  solution  in  clean  cases.  When 
any  form  of  infection  is  present,  one  of  the  above-mentioned  anti- 
septic solutions  may  be  employed.  Lysol  and  creolin  have  the 
advantage  for  this  purpose  of  acting  somewhat  as  a  lubricant. 
The  legs  must  then  be  covered  with  sterile  sheets,  and  the  perineal 
region  entirely  covered  save  opposite  the  vulva. 

The  author  has  entirely  abandoned  the  mercury  salts  in  ob- 
stetric and  gynecologic  work.  If  they  be  used  in  strengths  of 
I  :  500  or  I  :  looo  they  are  apt  to  hurt  the  tissues,  and  there  is  risk 
of  dangerous  absorption  if  they  be  used  as  internal  douches. 
Chinosol  and  formaldehyd  are  as  effective  as  the  mercury  salts, 
and  cannot  be  absorbed  so  as  to  injure  the  patient,  when  used  in 


ANESTHESIA   IN  LABOR.  245 

douches.  (The  author  knows  of  several  cases  in  which  corrosive 
sublimate  douches  varying  from  i  :  4000  to  i  :  2000  have  caused 
symptoms  of  mercury  poisoning.  In  one  instance  death  was 
caused  by  absorption  of  the  drug  after  several  days'  douching 
with  a  I  :  4000  solution.) 

Air  infection,  formerly  thought  to  be  so  important,  is  now 
known  to  be  of  very  little  importance  and  may  almost  be  disre- 
garded. Too  often  has  the  death  of  a  woman  been  attributed  to 
a  faulty  sewer  (perhaps  a  hundred  yards  away  from  the  patientj 
when  the  physician's  dirty  fingers  have  been  at  fault. 


CHAPTER   V. 

ANESTHESIA  IN  LABOR. 

In  obstetric  practice  a  general  anesthetic  may  be  used  for  two 
purposes  : 

1.  To  produce  mere  analgesia  for  the  relief  of  the  woman's 
suffering. 

2.  To  produce  deep  anesthesia  in  order  that  unconsciousness 
and  complete  muscular  relaxation  may  be  brought  about. 

In  the  great  majority  of  labors  it  is  only  necessary  to  attain  the 
first  of  these  objects.  As  a  rule,  the  anesthetic  should  not  be  used 
during  the  first  stage,  because  when  once  it  has  been  given  to  the 
patient  it  is  difficult  to  withhold  it  during  the  remainder  of  the 
labor.  Moreover,  too  prolonged  administration  may  weaken  the 
uterine  contractions  and  impair  the  cardiac  strength.  There  are, 
however,  exceptional  cases,  in  which  various  complications  make 
early  administration  advisable.  These  will  be  described  at  a  later 
period. 

To  obtain  analgesia,  chloroform  is  by  far  the  most  satisfactory 
anesthetic  because  of  its  quickness  of  action,  ease  of  administration, 
and  comparative  freedom  from  distressing  after-effects.  When  it 
is  used  in  a  room  in  which  gas  is  burning  the  vapor  of  the  drug 
becomes  decomposed,  and  may  be  very  irritating  to  the  air 
passages  of  the  patient  and  other  persons  present. 

The  chloroform  should  be  sprinkled  in  drops  on  a  flannel  in- 
haler or  on  a  handkerchief  held  over  the  nose  and  mouth,  the  face 
having  been  coated  with  vaselin.  In  many  cases  a  very  few  drops 
satisfy  the  patient,  the  analgesia  produced  being  largely  due  to 
autosuggestion.  She  has  longed  for  the  drug  and  believes  that  it 
will  relieve  her  suffering,  and  feels  the  greatest  satisfaction  when 
she  smells  the  first  drops.  The  physician's  duty  is  to  strengthen 
the    suggestion.     The   chloroform   should   be   started  as  late  as 


246  ANESTHESIA    IN  LABOR. 

possible  in  the  second  stage,  and  should  be  given  when  a  pain 
begins,  being  removed  in  the  intervals.  Usually  it  need  be  pushed 
only  when  the  vulva  is  being  much  distended,  a  cause  of  much 
distress,  as  a  rule. 

Judiciously  employed  in  this  manner,  there  is  little  danger  of 
prolonging  labor  by  causing  a  weakened  action  of  the  uterus. 
Neither  is  there  a  danger  of  producing  postpartum  inertia  and 
hemorrhage.  Too  often  has  the  drug  been  blamed  for  these  com- 
plications when  it  has  been  due  to  a  long,  tedious  labor  or  to  one 
that  has  been  hurriedly  brought  to  a  close. 

When  deep  anesthesia  is  necessaiy  in  obstetric  work,  the  same 
rules  and  considerations  are  to  be  observed  that  are  now  estab- 
lished in  regard  to  surgical  operations.  In  America  ether  is 
generally  preferred  for  these  purposes  unless  there  be  distinct 
contraindications  to  its  use.  The  full  physiologic  effect  of  the 
drug  is  necessarj^' — viz.,  abolition  of  consciousness  and  of  voluntary 
and  reflex  muscular  m.ovements. 

Hensen,  after  an  exhaustive  study  of  the  effects  of  ether  and 
chloroform  on  labor,  states  that  after  ether  anesthesia  the  muscular 
activity  is  much  more  quickly  restored  than  after  chloroform — five 
to  twenty-five  minutes  after  the  former,  two  hours  after  the  latter. 
Bearing  in  mind  their  influence  on  the  postpartum  condition  of  the 
uterus,  he  advises  that  ether  should  alwa)-s  be  used  for  operative 
procedures  save  when  there  is  a  contraindication  to  the  use  of 
the  drug. 

Recently  ethyl  chlorid  has  been  recommended  in  obstetric 
work.  Lepage  and  Lorier  state  that  it  is  easily  administered,  the 
dose  being  always  the  same.  Anesthesia  is  obtained  in  thirty  to 
sixty  seconds,  and  lasts  four  minutes  without  repeating  the  dose ; 
the  return  to  consciousness  is  rapid  and  usually  without  nausea. 
It  is,  therefore,  of  great  advantage  when  a  short  anesthesia  is 
required. 

Spinal  Anesthesia  with  Cocain. — Since  Kreis  published 
an  account  of  6  cases  of  delivery  at  Bumm's  Clinic  at  Basel,  a  con- 
siderable number  of  obser\^ations  have  been  made,  but  this  method 
of  obtaining  anesthesia  has  not  been  widely  adopted  in  obstetric 
practice.  In  America  Marx  has  had  the  widest  experience.  The 
injection  is  given  as  in  ordinary  surgical  cases,  but  when  the 
woman  cannot  bend  well  forward  the  left  lateral  position  is  adopted. 
The  analgesia  is  usually  complete  as  regards  all  the  factors — 
uterine  contractions,  dilatation  of  the  cervix,  distention  of  the 
vagina  and  vulva,  etc.  All  operations  may  be  performed  except- 
ing, usually,  those  involving  the  introduction  of  the  hand  in  the 
uterus,  the  cocain  acting  as  a  stimulus  to  uterine  contractions. 
Complete  analgesia  lasts  from  one  and  a  half  to  two  hours ;  some- 
times longer.  It  may  be  prolonged  by  continued  injections,  but 
the  increased  dosage  is  liable  to  produce  toxic  effects. 


SPINAL   ANESTHESIA    WITH  COCA  IN.  247 

The  injection  usually  causes  cramps  and  trembling  in  the  legs, 
nausea,  headache,  and  rise  of  temperature  ;  these  symptoms  usually 
subside  quickly,  but  occasionally  may  persist  one  or  more  days. 
Marx  states  that  the  hydrobromate  of  hyoscin  (pL  gr.)  best 
counteracts  these.  The  uterine  contractions  continue  during  the 
anesthesia,  Doleris  and  others  stating  that  they  increase  in  force 
and  frequency.  Several  authors  have,  however,  reported  cases  in 
which  cocain  caused  weakening  of  the  pains. 

A  considerable  number  of  normal  cases  have  required  artificial 
delivery  owing  to  the  absence  of  contraction  of  the  abdominal 
muscles.  The  patient  not  being  conscious  of  the  uterine  pains, 
only  exercises  voluntaiy  expulsive  efforts  when  asked  to  do  so. 
As  regards  the  influence  on  the  fetus,  if  the  dose  of  \  gr.  be  not 
exceeded  the  fetus  is  not  affected.  Larger  doses  cause  slowing  of 
the  fetal  heart  and  ma)'  produce  asph}'xia. 


PART   III. 

THE    PUERPERIUM. 


CHAPTER   I. 
ANATOMY  AND  PHYSIOLOGY, 

The  puerperium  is  the  period  during  which  the  genitaUa 
gradually  recover  from  the  marked  alterations  that  they  have 
undergone  during  pregnancy  and  labor. 

On  the  average  its  duration  is  generally  considered  to  be  about 
six  weeks  ;  yet  it  is  frequently  longer.  It  is  to  be  noted  that  the 
tissues  never  return  to  the  condition  that  existed  before  pregnancy, 
many  variations  being  found  in  different  cases.  As  a  rule,  it  may 
be  stated  that  there  is  a  more  marked  distinction  between  the  pre- 
pregnant  and  postpuerperal  state  in  primiparae  than  in  multiparae. 
In  the  latter  it  is  often  difficult  to  make  out  the  change  that  has 
resulted  from  a  pregnancy  and  labor.  The  following  facts  regard- 
ing the  anatomy  of  the  pelvis  and  its  contents  are  mainly  derived 
from  investigations  made  by  myself  on  a  number  of  cadavera, 
which  were  studied  by  means  of  frozen  sections. 

Uterus. — At  the  Beginning  of  the  Puerperium. — The  uterus 
is  at  this  period  several  times  larger  than  in  the  nulliparous  con- 
dition. It  occupies  the  greater  part  of  the  pelvic  cavity,  the 
highest  point  of  the  fundus  being  only  i^  in.  above  the  brim. 
Measured  vertically,  the  highest  part  of  the  uterus  is  on  the 
average  about  4^  in.  above  the  top  of  the  symphysis,  the  bladder 
and  rectum  being  empty.  This  agrees  with  the  average  height 
found  by  Charpentier  in  the  living  subject.  Other  authors  give  a 
little  lower  figure  as  the  average,  Lusk  making  it  4.^  in.  Varia- 
tions depend  on  various  factors — /.  c,  the  size  and  condition  of 
the  uterus,  the  presence  or  absence  of  blood  within  it,  the  charac- 
ter of  the  pelvis,  the  state  of  the  rectum  and  bladder.  It  is  easy 
to  understand  how,  in  measuring  this  distance  on  the  living  sub- 
ject, too  short  a  suprapubic  height  might  be  given ;  it  is  usual  in 
such  cases  to  measure  from  the  symphysis  by  pushing  in  the 
abdominal  wall  until  the  hand  rests  on  the  bone ;  in  this  way  the 
thickness  of  the  abdominal  wall  pressed  against  the  symphysis 
may  be  left  out  of  account,  and  hence  the  measurement  may  not 

248 


UTERUS. 


249 


be  perfectly  accurate.  An  error  of  \  to  \  in.  might  thus  easily 
arise.  As  a  whole,  the  uterus  is  anteverted,  there  being  no  flexion 
between  the  cervix  and  body ;  the  fundus  may  be  directed  slightly 
backward  owing  to  the  pressure  of  the  intestines  against  its  an- 
terior part,  though  this  is  not  the  most  common  condition  of  the 
fundus  at  the  end  of  the  third  stage.  It  usually  appears  rounded, 
and  is  directed  to  the  front  against  the  anterior  abdominal  wall  (as 
in  my  second-day  specimen).  In  the  former  case  the  fundus, 
when  felt  through  the  abdominal  wall,  has  not  the  round  shape 
that  is  usually  found  after  labor.  The  explanation  of  this  would 
seem  to  be  the  flatteningf  of  the  fundus  from  before  backward. 


Fundus  uteri. 


Closed  sitius  in  uterine 
wall. 


Uterine     cavity     con- 
taining blood  clot. 


Symphysis  pubis 

Bladdey 

Utero-vesical  poucli 

Retraction  ring 

Lo-duer  liter,  segment. 

A  titer ior  fornix 


I^ower  part  o/ziagiiia. 
Perineum. 


Promontory. 


—  Placental  site. 


Cavity    of   uterus 
above  cervix. 

Cerzn'x. 

Pouch  of  Douglas. 
"  Upper  part   of 
vagina. 


Fig.    128. — Vertical    mesial    section   of  uterus   at   close    of  labor, 

delivery. 


five   minutes   after 


There  can  be  no  doubt  that  in  normal  conditions  the  uterus  at  the 
beginning  of  the  puerperium  is  anteverted  or,  it  may  be,  ante- 
flexed,  the  long  axis  of  the  body  being  at  right  angles  to  the  brim. 

In  the  specimen  that  I  have  described  three  parts  can  be  dis- 
tinguished in  the  uterine  wall — viz.,  upper  uterine  segment,  lower 
uterine  segment,  and  cervix. 

Upper  Uterine  Segment. — This  forms  the  great  mass  of  the 
uterus.  Its  walls,  owing  to  retraction  and  contraction,  are  thick 
and  have  a  compact  appearance ;  it  can  be  moulded,  however,  by 
the  structures  against  which  it  rests.  It  is  of  a  pale  gray-pink 
color,  darker  opposite  the  placental  site.      Its  vessels  are  closed^ 


250 


ANATOMY  AND   PHYSIOLOGY. 


the  tissues  appearing  quite  bloodless.  It  is  thus  evident  that  in 
this  condition  very  little  blood  can  circ  date  in  the  wall. 

Lower  Uterine  Segment. — This  still  exists,  though  veiy  much 
shorter  than  during  labor.  It  is  best  marked  in  the. anterior  wall 
of  the  uterus,  where  it  appears  scarcely  more  than  half  an  inch  in 
length.  Above  it  passes  abruptly  into  the  thick  upper  uterine 
segment,  while  below  it  suddenly  joins  the  well-marked  cervix. 
Posteriorly  it  is  not  so  thin,  and  passes  more  gradually  into  the 
upper  uterine  segment  above  and  the  cervix  below.  There  exists 
a  well-marked  retraction  ring ;  this  is  not  the  same  as  the  retrac- 
tion ring  of  labor.  It  is  relatively  near  the  cervix — i.  c,  the  upper 
uterine  segment  of  labor  has  been  added  to  inferiorly  by  the 
amount  of  the  lower  uterine  segment  taken  up  into  it. 

Cervix. — The  cervix,  though  quite  thick,  is  not  restored  to  the 


Uterine  cavity. 


Cervix. 


Body  of  uterus- 


Left  ilio-pccii- 

neat  eminence. 
Peritonenjn . 

(Compressed 
broad  liga- 
ment ivith 
closed  sinuses. 

'Jreter. 


Vagina. 
Rectum. 

Coccyx. 


Fig. 


129.- 


-Vertical  oblique  section  of  pelvis  in  the  beginning  of  the  puerperium,  five 
minutes  after  delivery. 


preparturient  condition.  It  is  considerably  flattened  from  above 
downward,  though  this  is  probably  partly  due  to  the  pressure  of 
the  upper  uterine  segment ;  its  cavdty  is  also  partly  everted.  It 
is  congested,  and  thus  stands  out  in  sharp  contrast  with  the  body 
of  the  uterus.  It  is  impossible  clinically  to  define  with  accuracy 
either  the  os  externum  or  os  internum,  especially  the  latter ;  hence 
the  long  tables  of  measurements  of  the  cervix  and  body-cavity 
given  by  Milsom,  Sinclair,  Auefage,  Charpentier,  and  E.  Martin 
are  not  accurate.  These  writers  have  made  the  mistake  of  sup- 
posing that  the  prominent  lower  edge  of  the  retraction  ring  is  the 
OS  internum.  The  latter  region  in  the  early  puerperium  cannot 
be  placed  with  accuracy  even  after  the  most  careful  microscopic 
examination,  because  of  the  transitional  nature  of  the  epithelium 


UTERUS. 


251 


lining  the  uterus  at  its  level.  There  is  another  reason  why  these 
cavity  measurements  are  fallacious.  The  folding  between  the 
upper  uterine  segment  and  the  cervix  is  not  taken  into  account. 
The  actual  length,  therefore,  of  the  cavity  of  the  uterus  will  be 
greater  than  that  obtained  by  the  use  of  a  sound  or  hysterometer. 
This  fallacy  is  well  brought  out  in  Fig.  128. 

The  resistant  ring  described  by  various  authors  as  constituting 
a  well-marked  boundary  between  the  corpus  and  cervix  uteri,  and 
called  by  them  the  os  internum,  is  in  reality  the  lower  edge  of  the 
retraction  ring.  It  is  the  boundary  between  the  upper  and  the 
lower  uterine  segment  only,  not  that  between  the  cervix  and  the 
rest  of  the   uterus.      To   appreciate  the   change   that   has   been 


Fundus  uteri. 


Bladder. 

Symphysis  pubis. 


Uretliral  orifice. 


Promontory. 


Caz'ity  of  uterus. 
Recttivi. 


Pouch  0/  Douglas. 
Utero-vesical 

pouch. 
Os  externum. 


Fig.  130. — Vertical  mesial  section  of  uterus,  second  day  of  puerperium. 


brought  about  in  the  uterine  wall,  it  is  interesting  to  compare  this 
early  puerperium  case  with  the  second  stage  of  labor  case  described 
by  Barbour  and  Webster,  in  which  the  cervix  is  greatly  thinned 
out,  and  the  retraction  ring  3^  in.  from  the  os  externum. 

The  uterus  as  a  whole  is  symmetrically  placed  in  the  pelvic 
cavity,  though  the  fundus  may  be  higher  above  the  brim  on  one 
side  than  on  the  other.  It  is  generally  believed  that,  after  the  third 
stage  in  a  normal  pelvis  and  with  empty  bladder  and  rectum,  the 
uterus  is  central  and  not  deflected  to  one  or  the  other  side. 
Clinical  observations  by  Borner  and  Croom  seem  to  show  that  in 
.some  cases  it  lies  nearer  to  one  .side  of  the  pelvis  than  to  the  other. 
Out  of  60  cases  Croom  found  that  in  4  the  uterus  was  nearer  the 


252  ANJ  TO  MY  AND  PHYSIOL  O  G  Y. 

left,  while  in  10  it  was  nearer  the  right  side  of  the  pelvis.  I  have 
found  that  by  clinical  observations  it  is  very  difficult  to  measure 
accurately  the  distance  between  the  uterus  and  the  bony  wall  in 
the  early  puerperium.  If,  as  in  my  case,  the  fundus  be  most  promi- 
nent on  one  side,  one  is  apt  to  conclude  that  the  uterus  as  a  whole 
is  deflected  to  that  side,  whereas  asymmetry  of  the  fundus  may 
be  coexistent  with  a  central  position  of  the  uterus  as  regards  the 
pelvic  cavity.  Also,  in  examining  a  large  number  of  women, 
unless  one  is  careful  to  include  only  those  who  have  had  a  per- 
fectly normal  pelvic  condition,  error  is  sure  to  arise  because  of  the 
deviations  of  the  uterus  due  to  previous  cellulitis  or  perimetritis. 
Moreover,  the  uterus  is  frequently  congenitalh'  nearer  one  side  of 
the  pelvis  than  of  the  other.  The  position  of  the  patient  also  is 
important.  As  Croom  has  shown,  the  results  will  not  be  the 
same  when  examination  is  made  in  the  dorsal  position  as  when  it 
is  made  in  the  lateral  position. 

There  was  no  rotation  in  most  of  my  specimens.  That  this  is 
not  always  the  case,  even  in  an  empty  condition  of  the  bladder 
and  rectum,  is  now  well  established.  Croom  found  in  40  cases 
that  10  only  were  rotated,  while  Borner  found  that  out  of  64 
cases  14  were  rotated.  Kehrer  has  found  that  out  of  lOO  cases 
30  were  rotated,  26  to  the  right  and  4  to  the  left.  In  the  majority 
of  cases  the  rotation  is  to  the  right — /.  c,  the  anterior  surface  of 
the  uterus  looks  to  the  front  and  right.  Neither  of  these  authors, 
however,  gives  the  amount  of  rotation.  Spiegelberg  says  it  is 
only  slightly  twisted.  This  is  an  exceedingly  difficult  point  to 
ascertain  with  accuracy  on  the  living  person.  It  is  best  deter- 
mined in  the  cadaver  by  means  of  frozen  sections,  the  parts  having 
been  undisturbed. 

Uterus  after  the  First  Day. — In  all  cases  after  the  first  day 
the  uterine  wall  cannot,  from  its  naked-eye  appearance,  be  divided 
into  the  three  portions  noticed  at  the  beginning  of  the  puerperium 
— viz.,  upper  and  lower  segments  and  cervdx.  Owing  to  the  con- 
tinued retraction  of  the  uterine  muscle  after  the  end  of  the  third 
stage,  the  lower  segment  is  gradually  taken  up  into  the  thick 
portion  above  it,  so  that  in  my  sections,  by  the  thirty-sixth  hour 
after  deliver}^  it  is  completely  obliterated,  the  body  of  the  uterus 
and  the  cervix  being  continuous  and  gradually  diminishing  in 
thickness  from  above  downward.  It  is  impossible  to  define  with 
accuracy  the  os  internum.  We  can  place  it  fairly  correctly  by 
noting  the  level  of  anteflexion,  the  level  of  attachment  of  the 
uterosacral  ligaments,  and  the  point  of  reflection  of  the  peritoneum 
from  the  uterus  to  the  bladder.  (In  my  early  puerperium  cases 
the  uterovesical  pouch  is  abnormally  high.)  One  can,  therefore, 
say  that  the  following  table  is  approximately  correct : 


UTERUS. 


253 


Case. 


Beginning  of  puerperium 

Second  day  

Third  day 

Fourth  day 

Sixth  day 

Fifteenth  day 


Cervix. 


Body. 


Inches. 


4f 
5i 
2,\ 


Whole  uterus. 

Cavity 

Inches. 

Inches 

6f 
7i 

<3t 

St 
6i 

5i 

4f 

31 

3f 

These  specimens  would  thus  seem  to  show  that  for  some  time 
after  labor  the  cervix  may  be  double  the  normal  nulliparous 
length.  The  shortening  that  takes  place  in  it  is  coincident  with 
that  which  takes  place  in  the  body,  though  probably  not  pm-i 
passu.  This  diminution  is  scarcely  perceptible  for  the  first  three 
or  four  days,  but  has  become  quite  marked  by  the  sixth  day  and 
well  pronounced  by  the  fifteenth  day.  Statements  are  made  in 
the  books  regarding  the  decrease  in  the  size  of  the  uterus,  based 


Symphysis  pubis. 
JRetropubic    tissues 
■with  simisfs. 


Urethral  orifice. 


Promontory. 


Uterine  cavity. 


Utero-vesical 

pouch . 
Pouch  of  Douglas. 

Rectum,  with  feces- 


Fig.  131. — Vertical  mesial  section  of  uterus,  sixth  day  of  puerperium. 


upon  clinical  observations  and  instrumental  measurements  on  the 
living  subject.  Owing,  however,  to  the  fallacies  associated  with 
these  methods  (already  pointed  out),  we  cannot  depend  upon  them. 
Lusk  says  that  a  diminution  in  the  size  of  the  uterine  body  is  appar- 
ent in  the  course  of  the  first  twenty-four  hours  ;  Winckel,  that  the 
decrease  commences  as  early  as  twelve  hours  afterward,  and  that 
there  is  a  daily  decrea.se  in  length  of  2.6  cm.  Frozen  sections  do 
not   in   any   way  tend  to   support  these   views,  but  are  more  in 


2  54  ANATOMY  AND   PHYSIOLOGY. 

agreement  with  Heschl,  who  says  that  the  change  does  not  begin 
until  at  least  the  fourth  day. 

On  the  fourth  day  the  uterus  has  practically  the  same  relation- 
ships as  on  the  second  day,  being  not  appreciably  altered  in  size 
or  position  in  the  majority  of  cases.  On  the  sixth  day  it  has  be- 
come lowered  somewhat,  and,  though  it  is  considerably  above  the 
brim  laterally,  it  appears  in  my  specimen  in  vertical  mesial  section 
just  below  the  brim  conjugate.  (In  this  case,  however,  owing  to 
the  feces  in  the  rectum,  the  uterus  is  somewhat  higher  than  it 
would  have  been  with  an  empty  condition  of  the  bowels.) 

In  the  description  of  puerperal  uteri  removed  from  the  body, 
published  by  different  authors,  Barbour  was  not  able  'n  the  early 
puerperium  to  trace  a  gradual  diminution  in  the  length  of  the  uterus 
corresponding  to  the  successive  days.  He  explained  this  by  the 
existence  of  pathologic  conditions  in  most  of  the  cases,  affecting 
involution.  It  is  evident,  however,  that  with  uteri  removed  from 
the  body  a  considerable  amount  of  error  is  likely  to  be  made  in 
comparing  measurements  made  in  different  cases  and  by  differ- 
ent observers.  The  amount  of  disturbance  of  parts  caused  by 
removal  from  the  body  is  not  inconsiderable,  and  varies  in  differ- 
ent cases.  The  measurements  that  most  approach  accuracy  are 
those  taken  after  frozen  sections  have  been  made.  On  the  fifteenth 
day  the  uterus  is  entirely  a  pelvic  organ.  Exactly  when  this  con- 
dition is  brought  about  one  cannot  yet  say.  Some  authors  place 
it  about  the  tenth  day. 

Frequently  the  uterus  is  found  retroverted  or  retroflexed  after 
the  tenth  day  without  being  of  any  pathologic  significance,  the 
condition  being  temporary,  return  to  the  normal  afterward  fol- 
lowing. The  ligaments  being  much  relaxed,  the  uterus  may  be 
turned  back  by  a  distended  bladder  or  bowel  and  by  prolonged 
lying  in  the  dorsal  position.  Of  course,  in  some  cases  the  organ 
may  ha\'e  been  retroverted  before  pregnancy. 

Naked=eye  Appearance  of  the  Uterus. — {a)  On  Section. — 
For  four  days,  at  least,  the  sections  have  the  appearance  of  con- 
tracted and  anemic  non-striped  muscle.  The  vessels  are  closed 
and  can  scarcely  be  distinguished  save  under  the  placental  site. 
On  the  sixth  day  the  uterus  has  a  darker  red  appearance,  the 
vessels  being  more  filled  Avith  blood  and  more  easily  distinguished. 
On  the  fifteenth  day  it  is  of  a  dark  reddish  color.  Of  my  specimens 
the  third-day  uterus  is  paler  than  any  of  the  others.  There  is  no 
appearance  of  the  extremely  fatty  appearance  that  Spiegelberg 
described  as  being  well  marked  between  the  fifth  and  the  eighth 
day,  nor  could  any  fat  globules  be  removed.  Neither  after  thaw- 
ing took  place  did  I  find  that  the  texture  was  extremely  soft  and 
friable.  It  was  compact  and  rather  to  be  described  as  of  a  spongy 
nature,  fairly  easily  indented  with  the  finger,  the  indentation,  how- 
ever, disappearing.     It  was  certainly  more  easily  torn  than  either 


UTERUS. 


255 


the  non-pregnant  or  the  pregnant  uterus.  The  cervix  is  softer 
than  the  body  and  is  somewhat  congested. 

if)  Outer  Surface. — During  the  early  days  of  the  puerperium 
the  peritoneum  is  wrinkled  over  a  considerable  part  of  the  uterus. 
The  wrinkhng  is  especially  marked  near  the  broad  ligaments  and 
the  pouch  of  Douglas.  It  results  from  the  diminution  in  the  size 
of  the  uterine  musculature  as  a  result  of  contraction  and  retrac- 
tion taking  place  to  a  relatively  greater  degree  than  the  shrinking 
of  its  peritoneal  covering.  By  the  sixth  day  the  wrinkling  has 
already  disappeared  save  near  the  junction  of  the  broad  ligaments. 

The  shape  of  the  uterus,  viewed  either  from  the  front,  the 
back,  or  the  side,  is  somewhat  pyriform,  diminishing  in  thickness 
from  above  downward.     In  some  cases  the  posterior  Avail  is  well 


Bladder. 

Symphysis  pubis 

Os  externum 


Urethral  orifice 


Promontory. 

\    '  Fzindiis  ofi  uterus. 
Cavity  0/  zderus. 


Portion  of  right 
utero-sacral  liga- 
ment. 

Posterior  fornix. 


"  Rectum. 


Fig.  132. — Vertical  mesial  section  of  retroverted  uterus,  fifteenth  day  of  puerperium. 


rounded,  the  anterior  being  more  flattened,  but  in  other  cases 
these  conditions  are  reversed.  The  puerperal  uterus  differs  in 
this  respect  from  the  normal  non-pregnant  uterus,  in  which  the 
posterior  wall  is  always  more  rounded  than  the  anterior.  It 
usually  returns  to  the  normal  condition  during  the  puerperium. 

[c)  Inner  Surface. — In  a  specimen  from  a  patient  who  died  of 
lung  disease  a  few  hours  after  labor  the  following  appearance  was 
presented : 

Three  areas  could  be  distinguished  : 

I.  Placental  Site. — This  occupied  the  posterior,  the  left  lateral, 
and  part  of  the  anterior  wall.  It  was  somewhat  lemon-shaped, 
the  length  being  4^  in.  and  the  greatest  breadth  2\  in.,  this  area 
being  about  1 1^  sq.  in.,  that  of  an  average  man's  palm.     In  gen- 


256  ANATOMY  AND  PHYSIOLOGY. 

eral  the  color  was  dark  red,  being  purplish  in  places.  It  was  more 
ragged  and  irregular  than  the  rest  of  the  inner  surface,  and  showed 
the  openings  of  torn  blood-sinuses. 

2.  Site  of  the  AttacJnnent  of  the  ]\Ieinbranes. — This  was  larger 
than  the  placental  portion,  less  deeply  colored,  being  of  a  red- 
brown  color,  and  less  ragged.  Toward  the  cervix  it  was  smoother 
than  in  its  upper  part.  Small  shreds  of  decidual  tissue  were  ad- 
herent all  over  it.  This  smoother  area  represented  that  part  of 
the  body-wall  that  formed  the  lower  uterine  segment. 

3.  Cervical  Area. — Two  parts  could  be  distinguished  in  this 
area — viz.,  a  lower  and  an  upper  portion.  The  lower,  about  i-i- 
in.  in  vertical  extent,  was  comparati\eh-  smooth,  with  ridges  here 
and  there,  due  probabl}'  to  the  remains  of  the  arbor  vitcE.  It  was 
deeply  congested,  and  ecchymoses  were  seen  below  the  surface. 
The  lower  edge  was  irregular. 

The  upper  portion  was  of  a  light  bluish  gray,  with  ridges  here 
and  there.  It  became  gradualh'  continuous  with  the  non-placental 
site  of  the  body-cavity,  there  being  no  well-marked  line  of  dis- 
tinction between  the  two.  (It  was  interesting  to  compare  the 
placental  site  with  the  placenta  from  the  same  case.  The  latter 
was  rounded  in  form,  with  an  average  diameter  of  about  6  in.,  its 
area  being  about  28  sq.  in.  It  was  evident  that  a  great  dispropor- 
tion between  the  area  of  the  placenta  and  the  site  of  its  former 
attachment  to  the  uterus  had  been  brought  about.) 

Relation  of  the  Uterus  to  the  Extra=uterine  Tissues  and  to 
the  Pelvis. — In  a  pelvis  of  average  size  at  the  beginning  of  the 
puerperium  the  uterus  fills  the  greater  part  of  the  pelvic  cavity 
and  compresses  the  extra-uterine  tissues.  This  compression  is 
especially  marked  between  the  uterus  and  the  bony  wall,  and  to  a 
much  less  extent  inferiorly  owing  to  the  softening  and  relaxation 
of  the  fascial  and  muscular  tissues  of  the  pelvic  floor.  In  conse- 
quence of  this  condition  of  the  parts,  the  circulation  of  blood  in 
the  intrapelvic  tissues  is  interfered  with  to  a  considerable  extent, 
those  parts  of  the  pelvic  floor  that  are  least  affected — i.  e.,  sub- 
pubic tissues,  vaginal  walls,  and  perineum,  being  congested,  the 
tissues  between  the  uterus  and  the  pelvic  wall,  however,  being 
anemic,  their  vessels  being  closed  or  nearly  closed. 

The  effect  of  contraction  and  retraction  of  the  uterus  on  its 
blood-circulation  has  already  been  referred  to.  The  compression 
of  the  organ  as  a  whole  on  the  tissues  outside  of  it  is  that  it 
further  interferes  with  the  flow  of  blood  to  itself;  the  ovarian 
and  the  uterine  arteries,  as  well  as  the  uterine  branches  of  the 
vaginal  arteries,  are,  owing  to  the  rearrangement  of  the  broad 
ligaments,  twisted,  and  at  the  same  time  compressed  against  the 
bony  wall  by  the  uterus.  The  only  part  of  the  uterus  that  is  not 
anemic  is  the  cervix.  It  is  neither  retracted  in  the  same  degree 
as  the  body,  nor  is  it  subject  to  much  compression  ;  at  the  same 


BLADDER.  25/ 

time  it  is  in  close  relation  to  the  vascular  vaginal  walls  and  para- 
vaginal tissues  that  have  been  so  recently  engorged  with  blood, 
and  may,  therefore,  become  deeply  congested. 

Owing  to  the  very  slight  diminution  in  the  size  of  the  uterus, 
this  condition  of  things,  as  my  sections  show,  is  kept  up  for  three 
or  four  days.  As  a  result,  bleeding  from  the  inner  surface  of  the 
uterus  is  greatly  interfered  with,  both  as  a  result  of  the  inter- 
ference of  contraction  and  retraction  with  the  intramural  circula- 
tion, and  also  through  the  mechanical  pressure  of  the  uterus  as  a 
whole  upon  the  broad  ligaments  and  the  tissues  lining  the  pelvic 
wall  containing  the  vessels  passing  to  it.  An  enormous  influence 
must  be  exerted  by  this  greatly  altered  blood-supply,  in  the  way 
of  initiating  or  stimulating  those  retrogressive  changes  that  bring 
about  the  involution  of  the  organ,  whatever  those  changes  may  be. 

Further,  the  condition  of  the  cervix  helps  us  to  understand 
why,  after  labor,  there  is  so  often  bleeding  as  a  result  of  even 
small  tears,  and  why,  if  the  laceration  has  extended  into  the  para- 
metric and  paravaginal  tissues,  so  rich  in  venous  sinuses,  there  may 
be  very  serious  hemorrhage.  If  this  cannot  be  checked  by  the 
ordinary  means—/,  e.,  hot  or  cold  douche,  it  is  evident  that  press- 
ure of  the  uterus  from  above  will  tend  to  diminish  the  flow 
of  blood  to  the  cervix  by  compressing  it,  while  a  firm  rectal  or  vag- 
inal plug  might  be  used  as  a  resisting  structure  against  which 
the  lacerated  part  could  be  more  firmly  compressed.  During 
several  years  I  have  made  careful  observations  regarding  post- 
partum hemorrhage  as  a  result  of  torn  cervix  in  a  considerable 
number  of  cases,  and  I  have  found  it  to  be  most  profuse  and  most 
difficult  to  stop  in  women  with  abnormally  large  pelves — /.  e., 
justomajor,  kyphotic,  or  in  those  with  abnormally  contracted 
pelves — /'.  €.,  rickety.  The  reason  of  this  is  clear  if  we  examine 
sections  of  such  pelves.  Barbour's  section  of  a  puerperal  woman 
with  a  kyphotic  pelvis  shows  that  the  uterus  in  no  way  acts  as  a 
plug  owing  to  the  great  size  of  the  upper  part  of  the  pelvic  cavity, 
and  the  condition  is  undoubtedly  more  favorable  to  excessive 
bleeding.  Indeed,  in  this  case  death  resulted  from  hemorrhage 
one  and  a  half  hours  after  labor.  In  a  well-marked  rickety  pelvis, 
as  Stratz's  section  shows,  the  uterus  cannot  sink  down  into  the 
pelvis,  but  remains  to  a  large  extent  above  the  brim,  the  cervix 
and  lower  uterine  segment  as  well  as  the  tissues  adjacent  to  them 
being  put  on  the  stretch  and  remaining  greatly  congested.  Stratz's 
case  also  died  of  postpartum  hemorrhage  half  an  hour  after  labor. 

Bladder. — My  frozen  sections  show  that  after  labor  the 
bladder  returns  to  practically  the  same  shape  it  had  before  labor, 
variations  being  noted  in  different  cases.  Immediately  after  labor 
it  may  lie  at  the  level  occupied  by  it  during  pregnancy,  or  even 
slightly  lower  ;  this  depends  mainly  upon  the  softening  and  stretch- 
ing of  its  supports  that  take  place   during  pregnancy  and  labor. 


258  ANATOMY  AND   PHYSIOLOGY. 

The  conditions  that  affect  the  lay  of  the  viscus  are  :  i.  Softening 
and  stretching  of  its  supports.  2.  Intra-abdominal  pressure.  3. 
Weight  and  position  of  the  uterus.  As  the  puerperium  progresses 
a  gradual  elevation  takes  place.  I  can  find  nothing  to  support  the 
statement  of  Halliday  Croom  that  immediately  after  labor  the 
bladder  is  on  a  higher  level  than  during  pregnancy. 

In  none  of  my  cases  is  it  exactly  central  in  the  pelvis.  It  is 
slightly  deflected  either  to  the  right  or  to  the  left  side.  From  the 
relation  of  the  bladder  to  the  uterus,  it  is  evident  that  its  distention 
with  urine  must  cause  the  uterus  to  be  less  anteverted — /.  c,  must 
make  the  fundus  take  a  higher  position  ;  probably,  also,  the  uterus 
must  be  raised  as  a  whole.  The  elevation  of  the  fundus,  found 
some  hours  after  delivery,  is  due  in  most  cases  to  the  filling  of  the 
bladder.  Filling  of  the  lower  part  of  the  rectum  also  raises  the 
uterus,  though  in  a  less  marked  degree. 

Vagina. — The  vagina  is  larger  in  all  its  dimensions  after  labo»" 
than  before.  Its  wall  presents  some  rugosities,  and  is  congested, 
edematous,  and  ecchymotic  in  some  places  near  the  lower  end. 
In  its  long  axis  it  usually  has  a  somewhat  sigmoid  shape.  In  the 
early  puerperium,  only  in  its  upper  part  are  the  walls  in  apposi- 
tion, the  lower  part  gaping  considerably.  Immediately  after  de- 
liver)^ the  vaginal  slit  has  the  usual  transverse  direction  in  its 
upper  portion  ;  in  the  lower  part,  owing  to  the  stretching  that  has 
taken  place,  the  direction  seems  to  be  more  vertical,  the  side  walls 
tending  to  approximate  one  another,  though  the  lower  part  of 
the  anterior  vaginal  wall  often  may  bulge  down  between  them. 
By  the  sixth  week  retraction  is  almost  complete,  though  the  surface 
is  less  rugose  than  before  the  pregnancy. 

Perineal  Body. — In  none  of  my  cases  was  there  any  marked 
tearing  of  the  perineum.  The  sections  show  that  after  labor,  in 
spite  of  the  great  stretching  of  this  part,  it  may  return  almost  to 
its  preparturient  shape,  though  it  is  soft  and  slightly  lower  in 
position.  As  the  puerperium  advances  it  becomes  firmer  and 
more  compact. 

Pelvic  F'loor  Projection. — Its  measurement  in  my  cases  is 
given  in  the  following  table  : 

First  day.  Second  day.         Third  day.         Fourth  day.         Sixth  day.  Fifteenth  day. 

2  in.  1 1  in.  i|  in.  2.\  in.  i ',-  in.  I  in. 

After  labor  we  thus  see  that  the  projection  is  greater  than  in 
the  nulliparous  condition. 

Compared  with  the  measurements  made  in  cases  of  pregnancy 
and  labor  by  Barbour  and  myself,  it  is  found  to  be  less  than  it  was 
during  the  second  stage,  and  about  the  same  as,  or  a  little  greater 
than,  it  was  in  advanced  pregnancy. 

Broad  I/igaments. — The  upper  part  of  each  broad  ligament, 
with  tube  and  o\-ary,  has  in  the  beginning  of  the  puerperium  much 


ABDOMINAL    WALL.  259 

the  same  appearance  as  in  the  pregnant  condition,  being  freely 
movable  and  having  its  layers  separated  only  by  a  small  amount 
of  tissue.  It  is  larger  than  in  the  non-pregnant  woman.  The 
lower  part  is  quite  different ;  it  has  scarcely  any  width  whatever, 
because  the  uterus  has  extended  between  its  layers  almost  to  the 
lateral  pelvic  wall.  The  peritoneal  layers  are  considerably 
wrinkled,  and  the  tissues  between  them  are  compactly  pressed 
between  the  uterine  and  pelvic  walls.  In  fact,  macroscopically  it 
is  very  difficult  to  say  where  the  uterine  muscle  stops  and  the 
broad-ligament  tissue  begins.  At  the  end  of  labor  the  highest 
part  can  be  traced  as  a  ridge  that  arises  in  the  iliac  fossa,  passing 
downward  and  forward,  crossing  the  brim,  its  layers  gradually 
getting  wider,  until  about  half  an  inch  below  the  brim  the  anterior 
layer  passes  to  the  bladder,  the  posterior  descending  to  form  the 
pouch  of  Douglas.  As  the  puerperium  advances  the  ligaments 
gradually  return  to  their  normal  nulliparous  condition. 

Tubes  and  Ovaries. — At  the  commencement  of  the  puer- 
perium they  lie  almost  entirely  above  the  brim  on  each  side, 
packed  between  the  uterus  and  the  pelvic  wall  and  covered  with 
intestines,  having  descended  from  the  position  occupied  by  them 
at  the  beginning  of  labor.  They  do  not  always  bear  the  same 
relation  to  one  another  and  to  the  uterus.  This  variation  is  mainly 
due  to  the  mobility  of  the  upper  free  portion  of  the  broad  liga- 
ments. This  mobility  chieily  affects  the  tubes,  allowing  them  to 
lie  either  in  front  of  or  behind  their  level  of  attachment  to  the 
uterus,  folded  in  various  ways.  The  ovaries,  however,  have  a 
much  more  limited  range  of  movement,  less  than  that  possessed 
by  them  either  in  the  non-pregnant  or  pregnant  woman.  Before 
labor  they  are  still  separated  from  the  wall  of  the  uterus,  the 
ovarian  ligament  being  well  marked.  After  labor,  however,  owing 
to  lateral  extension  of  the  retracted  and  contracted  uterus  into  the 
broad  ligaments,  the  ovaries  lie  closer  to  the  uterine  wall,  their 
inner  ends  appearing  to  be  attached  to  it  directly,  the  ovarian 
ligaments  being  practically  obliterated,  having  become  spread  out 
on  the  wall  of  the  uterus.  The  ovary,  thus  fixed  at  its  uterine 
end,  is  only  capable  of  moving  around  this  fixed  point ;  the  outer 
free  end  may  thus  be  found  in  front,  above,  behind,  or  below  the 
attached  end.  In  no  case  are  the  relations  the  same  on  both 
sides.  The  appendages  also  may  be  a  little  higher  on  one  side 
than  on  the  other.  During  the  first  four  days,  at  least,  they  do  not 
become  lowered  to  any  marked  extent.  When  they  reach  their 
normal  position  we  do  not  yet  know. 

Abdominal  Wall. — After  labor  the  abdominal  wall  is  lax 
and  often  wrinkled,  especially  in  multiparae.  Striae  are  visible  in 
large  or  small  numbers.  If  examination  be  made  it  will  be  found 
that  the  linea  alba  is  wider  than  in  the  non-pregnant  condition, 
the  recti-abdominis   muscles  being  separated,  especially  near  the 


2  6o  A  A' A  TOM  Y  AND   PH  \  SIOL  OGY. 

umbilicus.  Great  variations  are  found  in  the  extent  of  separation  ; 
it  is  most  marked  in  multiparae.  As  the  puerperium  advances  the 
laxity  of  the  wall  gradually  diminishes,  and  the  separation  of  the 
recti  becomes  less  marked.  In  some  cases  the  linea  alba  remains 
overstretched,  and  in  this  state  is  liable  to  be  a  cause  of  after- 
trouble. 

Involution  of  the  Uterus. — The  minute  changes  occurring 
in  connection  with  the  reduction  of  the  uterus  in  size  are  not  yet 
satisfactorily  determined.  Different  opinions  are  held  as  to  the 
nature  of  involution.  Robin,  in  1848,  claimed  that  it  is  due  to 
atrophy  of  the  muscular  fibers  without  destruction.  Kolliker,  in 
1849,  described  a  process  of  atrophy  accompanied  with  fatty 
degeneration.  Kilian,  in  1850,  from  his  studies  of  the  puerperal 
uterus  in  the  rabbit,  stated  that  the  musculature  became  reduced 
as  the  result  of  fatty  degeneration.  Heschl,  in  1852,  stated  that 
the  entire  musculature  was  removed  by  fatty  degeneration,  not  a 
fiber  of  the  old  uterus  being  left.  He  believed  that  the  change 
began  after  the  fourth  day,  taking  place  last  of  all  in  the  cervix. 
He  believed  that  formation  of  new  muscle  took  place  from  without 
inward.  Luschka  held  that  while  involution  is  associated  with 
the  appearance  of  fat  in  the  muscle  fibers,  the  latter  are  not  de- 
stroyed or  absorbed  but  only  diminish  in  size.  Meola,  in  1884, 
stated  that  the  process  of  involution  was  a  simple  granular  atrophy 
and  not  a  fatty  degeneration,  the  cause  of  the  atrophy  of  the 
muscle  being  a  hypertrophy  of  the  connective  tissue  that  takes 
place  during  the  puerperium.  Sanger  has  made  a  series  of  studies 
of  the  puerperal  uterus,  examining  the  muscle  fibers  after  macera- 
tion of  portions  of  the  uterine  wall  for  one  or  two  days  in  a  30 
per  cent,  solution  of  nitric  acid,  which  removed  the  intermuscular 
elements.  The  tissue  was  then  teased  with  needles  instead  of 
being  cut  into  sections.     He  made  the  following  measurements  : 

Length  of  the  fiber  in  the  normal  non-pregnant  uterus 34- 1/^ 

"  "  "        "           "        jiregnant               "       208. 7/z 

"  "  "        "       first  few  hours  post  partum 158.3// 

*'  "  "  at  the  fourth  day  of  the  puerperium    .         ...  li7-4/^ 

*'  "  "     in  the  beginning  of  the  second  week 82.7// 

"  "  "         "              "              "        third         " 32.7/i 

"  "  "     at  the  end  of  the  fifth  week 2./^.\[i 

As  regards  the  breadth  of  the  fibers,  he  found : 

Breadth  of  the  fiber  in  the  normal  non-pregnant  uterus 5.l/t« 

"  "  "        "       pregnant  uterus 10.6/j. 

"  "  "        "       first  few  hours  post  partum 12.2/j. 

"  "  "     at  the  fourth  day  of  the  puerperium lO-S/" 

"  "  "     in  the  first  half  of  the  second  week 8.0/1 

"  "  "     at  the  beginning  of  the  third        " 6.1// 

<<  "  "        "       end  of  the  fifth                     " 6.0// 

According  to  these  measurements  it  appears  that  during  the 
first  hours  after  labor  the  fibers  increase  in  breadth,  the  subsequent 


INVOLUTION  OF   THE    UTERUS.  26 1 

diminution  proceeding  more  slowly  than  does  the  shortening  in 
length.  The  greatest  loss  both  in  breadth  and  length  occurs  in  the 
third  week.  It  is  interesting  to  note  that  at  the  end  of  involution 
the  fiber  is  actually  shorter  than  it  is  in  the  normal  non-pregnant 
uterus.  Sanger  states  that  at  this  time  the  whole  uterus  in  nursing 
women  may  often  be  found  to  be  actually  smaller  than  in  the 
non-pregnant  state  (actually  superinvolutedj.  He  points  out  that 
longitudinal  and  transverse  folds  or  ridges  are  noticed  in  many 
fibers,  due  to  their  retracted  and  contracted  condition.  He  finds 
no  such  destruction  of  tissue  as  was  believed  to  take  place  by 
Heschl  and  Kolliker.  Fatty  degeneration  is  present  in  many 
fibers,  but  in  the  great  majority  of  instances  only  a  small  portion 
of  the  protoplasm  is  affected  ;  in  a  few  instances  where  it  is  ex- 
tensive, Sanger  believes  it  to  be  due  to  pathologic  processes.  He 
regards  the  most  prominent  changes  as  a  finely  granular  and  a 
hyaline  degeneration.  Benecke  has  also  described  a  hyaline 
change. 

These  changes  are  attributed  by  Sanger  to  three  factors — viz., 
increased  oxidation,  continuous  retraction  and  contraction,  and 
relative  anemia.  Much  of  the  protoplasm  is  oxidized  without  the 
intervention  of  any  fatty  change.  It  is  possible  that  much  of  the 
fat  is  derived  from  a  transformation  of  the  hyaline  matter.  No- 
where has  Sanger  found  fatty  detritus  outside  of  the  muscle  fibers. 
There  is  no  proof  that  there  is  increased  fat  in  the  blood  of  normal 
puerperal  women.  Sanger  states  that  degenerative  products  do 
not  enter  the  blood  as  such,  but  are  oxidized  v/here  they  are. 
The  intermuscular  connective  tissue  does  not  hypertrophy,  but 
undergoes  involution  changes  that  lead  to  its  diminution.  He 
states  that  when  the  fetus  dies  /;/  utero  involution  changes  occur 
in  the  uterus,  even  though  the  contents  be  not  at  once  expelled. 

Mayor,  in  1887,  described  a  process  of  atrophy  of  the  fibers 
not  uniform,  but  more  marked  in  the  submucous  than  in  the  sub- 
peritoneal area.  Some  fibers  escaped  this  change  and  had  a  waxy 
appearance.  In  the  first  twenty-four  hours  very  fine  fat  granules 
appear.  After  the  fourth  day  the  volume  of  the  fibers  diminish 
and  the  fatty  granules  become  more  numerous.  On  the  fifteenth 
day  the  reduction  amounts  to  one-half  or  two-thirds  of  the  original 
volume.  By  the  twenty-fourth  day  many  fibers  in  the  inner  part 
of  the  wall  are  empty  of  fat.  By  the  thirty-eighth  day  almost  all 
have  returned  to  their  normal  state.  Mayor  regards  this  change 
not  as  a  destruction,  but  as  an  atrophy,  accompanied  by  the 
transitory  appearance  of  fine  fatty  granules.  Along  with  this 
change  in  the  muscle  he  found  great  accumulation  of  fat  in  the 
intermuscular  connective  tissue,  from  which  it  was  gradually  ab- 
sorbed by  the  circulation. 

Helme,  in  1889,  in  studying  the  rabbit's  uterus,  found  no  fat 
whatever  in  the  muscle  during  the  puerperium.     The  cell-sub- 


262  ANATOMY  AND   PHYSIOLOGY. 

stance  of  the  fibers  became  dimmer  and  more  granular,  diminution 
in  size  gradually  taking  place.  It  occurred  simultaneously  in  all 
parts.  He  regarded  the  change  as  a  kind  of  peptonization  of  the 
cell-protoplasm,  the  fibers  diminishing  in  size  as  the  soluble 
material  became  absorbed  by  the  circulation.  Nowhere  could  he 
find  evidence  of  new  fibers  being  formed  from  pre-existing  muscle 
cells — /".  c,  no  nuclear  figures  could  be  observed.  The  connective 
tissue  showed  gradual  diminution  and  disappearance,  hyaline  and 
granular  changes  being  found  in  many  cells  and  fibers  ;  in  a  few 
places  very  fine  fat  granules  occurred  in  the  cells.  Scattered 
through  this  degenerating  connective  tissue  were  plasmodial 
masses  that  he  believed  to  perform  the  function  of  absorbing  the 
degenerating  material,  afterward  leaving  the  uterus  by  the  circu- 
lation, probably  being  broken  up.  The  great  majority  of  these 
had  disappeared  by  the  sixth  day  ;  a  few  that  remained  were  filled 
with  blood-pigment.  Helme's  view  that  the  muscle  protoplasm 
diminishes  by  a  process  of  peptonization  is  one  that  must  be  re- 
garded very  seriously.  It  is  not  unlikely  that  the  part  of  the 
fiber  that  is  thus  changed  may  be  absorbed  into  the  circulation  as 
soluble  peptones.  Several  observers  have  found  peptones  in  the 
urine  after  the  second  or  third  day.  Fischel  states  that  pep- 
tonuria is  a  constant  occurrence  in  the  normal  puerperium,  and 
that  it  was  not  found  in  a  case  in  which  Porro-Casarean  section 
had  been  carried  out.  Peptones  have  been  found  in  the  urine 
after  death  of  the  fetus  in  Jttcro,  though  expulsion  has  not  imme- 
diately taken  place. 

Broers  states  that  the  first  cause  of  diminution  in  volume  of 
the  muscle  fibers  is  a  discharge  of  glycogen  from  them,  the 
edematous  intermuscular  connective  tissue  at  the  same  time 
parting  with  much  water  through  absorption.  The  glycogen  is 
probably  removed  by  lymphatics.  The  muscular  coats  of  the 
compressed  arteries  also  lose  glycogen.  He  states  that  after 
twenty-four  hours  fatty  degeneration  may  be  detected  in  the 
muscle  fibers. 

Uterine  involution  varies  in  different  cases.  Knapp  states  that 
it  is  quicker  in  multiparae.  Maclennan  believes  that  this  is  true 
only  for  the  first  week.  It  is  stated  that  instrumental  and  tedious 
labors  and  those  associated  with  much  loss  of  blood  retard  invo- 
lution. The  older  the  primipara  the  less  rapid  it  is ;  nursing 
favors  it.  There  is  some  difference  of  opinion  as  to  the  influence 
of  ergot  in  this  connection.  (Subinvolution  is  considered  under 
"  Pathology  of  the  Puerperium.") 

Chang-es  in  the  Vessels  of  the  Uterus. — My  frozen  sec- 
tions demonstrate  the  anemic  condition  of  the  great  mass  of  the 
uterus,  due  partly  to  pressure  of  the  organ  against  the  vessels 
external  to  it,  but  mainly  to  the  marked  change  in  the  branches 
running  in  its  wall.     When   the  pregnant  uterus,  so  richly  vas- 


CHANGES  IN   THE    UTERINE   MUCOSA.  263 

cularized,  is  compared  with  the  early  puerperal  uterus  in  its 
retracted  and  contracted  state,  it  is  evident  that  the  vessels  must 
have  been  greatly  twisted  and  compressed,  circulation  through 
many  of  them  being  an  impossibility.  The  least  interference  is  in 
the  cervical  region.  Many  of  these  vessels  become  closed  by 
adhesions  in  the  lumina  after  disappearance  of  the  endothelium, 
which  often  undergoes  hyaline  and  granular  changes.  In  some 
proliferation  of  the  intima  or  thickening  of  the  outer  covering  is 
found,  though  this  may  have  been  in  progress  before  labor  began. 
In  several  arteries  hyaline  changes  in  the  entire  thickness  of  the 
wall  are  noticed.  Many  of  the  vessels  that  remain  patent  after  the 
puerperium  are  markedly  convoluted  and  thickened ;  in  parts  the 
lumen  is  large.  These  conditions  may  be  found  years  after  labor. 
Toward  the  cavity  of  the  uterus  thrombi  form  in  the  blood-sinuses 
that  have  been  torn  across.  The  red  blood-corpuscles  left  in 
vessels  whose  circulation  has  been  obstructed  and  those  that  have 
escaped  into  the  surrounding  tissue  are  broken  up,  the  pigment 
being  partly  removed  by  white  corpuscles,  part  of  it  remaining 
ill  siiti. 

Changes  in  the  Uterine  Mucosa. — Immediately  after  de- 
livery the  appearance  of  the  decidual  tissue  is  very  different  from 
that  which  is  found  before  labor  begins.  Owing  to  uterine  re- 
traction and  contraction,  notwithstanding  the  amount  removed 
with  the  placenta  and  membranes,  it  is  considerably  thickened, 
especially  in  the  placental  area.  The  surface  of  this  area  is  irregu- 
lar, being  thrown  into  a  series  of  elevations  and  depressions.  Its 
thickness  is  mainly  made  up  of  the  strands  of  the  spongy  portion  ; 
remains  of  the  compact  layer  exist  only  as  a  thin,  broken  layer. 
Though  very  spongy  in  nature,  the  arrangement  of  spaces  and 
trabeculae  is  very  different  from  that  which  existed  in  the  prepar- 
turient  condition.  Then  the  spaces  were  mostly  flattened,  some- 
what parallel  to  the  muscular  part  of  the  uterine  wall.  In  the 
postpartum  condition  the  spaces  are  very  irregular  in  size  and 
shape,  and  are  no  longer  mainly  parallel  with  the  muscle.  The 
vessels  of  the  decidua  are  greatly  contorted  and  compressed  in 
various  directions.  In  a  considerable  number  of  places  the 
trabeculae  appear  to  have  been  torn  across.  All  of  these  changes 
are  consequent  upon  uterine  retraction  and  contraction. 

In  the  non-placental  area  the  decidua  is  thinner,  but  its  arrange- 
ment is  similar  to  that  of  the  placental  area.  In  both  areas  the 
musculature  is  sometimes  quite  bare  in  spots.  These  are  either 
parts  from  which  the  decidua  has  been  entirely  absorbed  by  the 
end  of  pregnancy,  and  which  had  not  been  entirely  obliterated 
during  the  diminution  of  the  uterus  in  size,  or  the  decidua  had 
been  very  thin  and  had  been  removed  along  with  the  placenta  or 
membranes. 

Soon  after  labor  the  surface  of  the  decidua  becomes  covered 


264  ANATOMY  AND   PHYSIOLOGY. 

with  a  layer  of  blood  and  fibrin,  varying  in  thickness  in  different 
parts,  being  generally  most  marked  over  the  placental  area,  where 
it  fills  the  depressions  on  the  surface  and  the  openings  of  the 
maternal  sinuses.  Gradually  well-marked  thrombi  develop  in  the 
latter,  forming  rounded  elevations  on  the  surface.  Thereafter 
there  is  a  gradual  transformation  in  these  tissues.  The  large, 
irregular  spaces  of  the  spongy  layer  gradually  diminish  in  size ; 
many  decidual  cells  undergo  a  process  of  involution,  hyaline, 
granular,  or  fatty  changes  taking  place  in  them,  some  being  dis- 
charged in  the  lochia.  Other  portions  of  the  connective  tissue 
may  also  break  down  and  escape.  The  thrombi  in  the  vessels 
gradually  become  organized  and  shrink.  Deposits  of  blood-pig- 
ment may  remain  in  the  placental  area  for  a  considerable  time. 
Many  variations  are  found  as  regards  the  disappearance  of  all 
traces  of  decidual  cells.  In  some  instances  they  have  been  found 
in  scrapings  taken  from  the  uterus  months  after  a  labor  or  abor- 
tion. In  seven  or  eight  weeks  the  endometrium  is  entirely  re- 
formed, being  lined  by  columnar  epithelium  and  containing 
numerous  glands. 

lyOchial  Discharge. — For  some  time  after  labor  a  fluid  dis- 
charge known  as  the  lochia  escapes  from  the  genital  canal.  In 
the  first  three  or  four  days  it  is  composed  almost  entirely  of  blood 
and  small  coagula.  When  the  uterus  does  not  remain  firmly  re- 
tracted and  contracted  the  clots  may  be  of  considerable  size. 
Thereafter  the  color  becomes  light  reddish  brown  as  the  amount 
of  blood  diminishes,  the  flow  consisting  mainly  of  blood-serum 
mixed  with  red  and  white  corpuscles,  broken  down  decidual  ele- 
ments from  the  interior  of  the  uterus,  epithelium  from  the  vaginal 
wall,  and  mucus.  The  discharge  becomes  paler  in  color,  and  by 
the  seventh  day  is  pale  yellow  or  greenish.  Afterward  it  becomes 
somewhat  white  and  opaque,  according  to  the  number  of  pus  cells 
in  it.  Kronig  states  that  normally  pus  does  not  come  from  the 
interior  of  the  uterus,  but  from  torn  surfaces  of  the  cervix  and 
vagina.  If  these  are  absent  there  may  be  little  or  no  creamy  con- 
dition. The  lochia  is  normally  sterile.  The  ordinary  vaginal 
micro-organisms  may  be  found  in  it.  At  the  vulva  it  becomes 
contaminated  by  many  others. 

At  first  the  discharge  is  alkaline.  In  the  later  stages  it  be- 
comes slightly  acid  in  the  vagina,  probably  due  to  the  influence 
of  various  non-pathogenic  vaginal  organisms. 

The  quantity  of  discharge  varies  considerably  and  is  very  dif- 
ficult to  estimate  accurately.  (Gassner  has  estimated  it  at  54  oz., 
Giles  at  10  oz.)  Normally  it  becomes  scanty  after  the  fifteenth 
day,  and  may  have  almost  disappeared  by  the  twenty-first  day. 
It  may,  however,  last  two  or  three  weeks  longer.  It  lasts  longer 
in  non-nursing  than  in  nursing  women,  and  is  more  profuse  where 
involution  from  any  cause  is  imperfect.     During  the  first  three  or 


ALIMENTARY   TRACT— METABOLISM.  265 

four  days  the  odor  of  the  lochia  is  that  of  fresh  blood  or  raw 
meat.  Later  it  has  a  slightly  disagreeable  or  sickening  smell.  A 
fetid  odor  is  due  to  the  influence  of  saphrophytes  growing  on 
blood-clot  or  on  dying  or  dead  tissue  in  some  part  of  the  genital 
canal.  Sometimes  marked  changes  in  the  color  of  the  lochia  are 
caused  by  pigment-producing  organisms. 

Fischel  and  others  have  pointed  out  that  the  lochia  may  con- 
tain peptones  as  well  as  the  urine.  The  former  found  them  in  the 
uterine  musculature,  but  not  in  the  remains  of  the  decidua  lining 
the  uterus. 

Alimentary  Tract. — The  bowels  tend  to  be  constipated  for 
several  days  after  labor.  This  is  partly  due  to  the  increased 
activity  of  the  skin,  kidneys,  and  breasts,  and  to  the  loss  of  fluid 
in  the  lochia.  It  is  also  thought  to  be  due  to  weakening  of  intes- 
tinal peristalsis  as  a  result  of  the  laxity  of  the  abdominal  parietes 
and  the  change  in  intra-abdominal  pressure.  But  very  often  the 
rectum  is  loaded,  showing  that  peristalsis  in  the  rest  of  the  intes- 
tine may  be  satisfactory.  Thirst  is  usually  marked.  There  is 
generally  some  enfeeblement  of  digestion  for  solid  food. 

Metabolism. — The  body  weight  is  less  after  labor  than  before. 
This  is  due  to  the  loss  of  the  fetus,  placenta,  membranes,  liquor 
amnii,  blood,  and  sweat.  Diminution  continues  during  the  first 
eight  or  nine  days,  varying  in  different  cases.  Non-nursing  women 
and  primiparae  lose  less  than  nursing  women  and  multiparas.  The 
loss  is  actually  but  not  relatively  greater  in  proportion  to  the 
body  weight.  Baumann  estimates  the  loss  one-tenth  of  the  total. 
There  seems  to  be  a  lessening  of  body  metabolism  in  the  early 
puerperium.  According  to  Grammatikati,  the  excretion  of  nitrog- 
enous elements  has  a  marked  relation  to  milk  secretion.  In  the 
first  day  or  two  it  is  less  than  when  the  milk  flow  begins.  When 
the  child  is  removed  from  the  breast  the  urea  excretion  diminishes. 
In  40  analyses  as  to  the  occurrence  of  phosphates  in  the  urine, 
he  found  a  marked  increase  on  the  first  day,  diminution  on  the 
second,  and  a  gradual  increase  afterward,  as  the  milk  secretion 
became  established  ;  then  there  was  a  lessening  until  the  sixth 
day.  He  obtained  similar  results  as  regards  the  sulphur  com- 
pounds.    The  sodium  chlorid  gradually  increased. 

Great  variations  are  found  in  the  quantity  of  urine  passed. 
This  is  affected  by  the  amount  of  lochia  and  sweat,  by  the  condi- 
tion of  the  feces,  and  by  the  liquids  taken  into  the  system.  Yet, 
apart  from  these  conditions,  it  is  probable  that  the  quantity  dimin- 
ishes after  labor  until  about  the  fourth  day,  when  the  minimum  is 
reached.  Kehrer  estimates  that  in  the  early  days  there  is  21  per 
cent,  less  than  the  quantity  passed  before  labor.  Kleinwachter 
stated  that  the  average  specific  gravity  in  the  puerperium  is  1015 
to  1016.  Sugar  is  frequently  found  in  the  urine,  generally  ap- 
pearing about  the  third  day.     It  is  not  grape  sugar,  but  lactose, 


266  ANATOMY  AND   PHYSIOLOGY. 

and  is  derived  from  the  changes  in  the  breasts.  The  quantity 
varies  considerably,  being  most  marked  when  the  breasts  are  im- 
perfectly emptied.  Some  have  claimed  that  the  sugar  is  hepatic 
in  origin.  Carstairs  Douglas  finds  that  96.5  per  cent,  of  cases 
show  lactosuria  after  full  lactation  has  been  established.  It  may 
last  several  days  after  nursing  has  ceased.  He  states  that  there 
is  no  very  good  test  for  lactose  in  urine,  but  holds  that  a  specimen 
that  responds  fairly  well  to  Fehling's  test  (fallacies  being  excluded), 
but  does  not  yield  crystals  with  phenylhydrazin,  and  does  not 
ferment  (except  very  slowly)  with  yeast,  is  practically  certain  to  be 
lactose.  Winckel  states  that  acetone  is  found  in  small  quantities. 
Lehmann  found  butyric  acid  in  cases  where  there  was  no  nursing. 
Peptones  are  found  in  the  urine  after  the  third  day,  rarely  before; 
Truzzi  states  that  they  most  frequently  occur  on  the  fourth  or 
fifth  day,  rarely  after  the  tenth.  It  is  probable  that  they  are 
derived  from  the  involution  of  the  uterus,  as  has  been  suggested 
by  Helme  and  others.  Fischel  has  reported  that  they  were  absent 
in  a  case  in  which  the  uterus  was  removed  by  Porro-Csesarean 
section.  He  stated  that  peptonuria  is  constant  in  the  normal 
puerperium. 

Urination. — For  some  hours  after  labor,  varying  in  different 
cases,  there  is  usually  no  desire  to  urinate,  and  the  urine  may 
largely  accumulate  in  the  bladder.  This  is  mainly  due  to  the 
altered  intra-abdominal  relationships  and  to  the  great  relaxation 
of  the  parietes,  whereby  there  is  easy  accommodation  of  the  dis- 
tended viscus.  In  some  cases  there  may  be  a  reflex  inhibition  of 
the  desire  to  urinate,  or  of  the  detrusor  muscle  of  the  bladder  as 
a  result  of  injuries  to  the  urethra  or  external  genitals  ;  or  the 
sphincter  of  the  urethra  may  be  reflexly  markedly  contracted. 
In  some  cases  there  is  merely  inability  to  urinate  while  the  woman 
lies  in  the  dorsal  position,  and  the  function  may  be  normal  if  she 
is  raised  in  bed. 

Perspiration. — The  skin  is  usually  moist,  the  sweat  glands 
acting  freely.  Under  modern  conditions  of  cool,  well-aired  rooms, 
women  do  not  exhibit  the  profuse  sweats  that  were  common  in 
old  days,  when  they  were  kept  too  warm.  The  distinct  odor  due 
to  fatty  acids  in  the  abundant  perspiration  was  regarded  as  a 
normal  and  favorable  sign,  its  absence  indicating  danger. 

Respiration. — After  labor  abdominal  breathing  again  comes 
into  play,  the  number  of  respirations  diminishing.  Kehrer  finds 
that  the  chest  circumference  diminishes  from  the  highest  point 
reached  in  pregnancy  to  the  third  day  of  the  puerperium  by  9.5 
per  cent,  in  primiparae,  and  by  8.8  per  cent,  in  multiparse ;  the 
transverse  diameter  by  9.6  per  cent,  in  primiparae,  and  by  6.7  per 
cent,  in  multiparae.  There  is  a  narrowing  of  the  transverse  and 
an  increase  of  the  anteroposterior  diameters.  As  regards  lung 
capacity,  different  statements  are  made.     Dohrn  finds  in  examining 


TEMPERA  TUKE — BL  0  OD.  26/ 

lOO  cases  that  on  the  fourteenth  day  of  the  puerperium  it  is 
greater  than  in  the  pregnant  condition  in  60  per  cent.,  unchanged 
in  14  per  cent.,  and  diminished  in  26  per  cent.  Vagas,  in  50 
cases,  found  it  unchanged  in  26  cases,  increased  in  17,  and  de- 
creased in  7.     The  explanation  of  the  differences  is  not  known. 

Temperature. — The  normal  puerperium  runs  its  course  with- 
out febrile  phenomena.  Yet  in  many  cases  variations  in  tempera- 
ture are  found  within  the  range  of  the  normal.  Frequently  there 
is  a  slight  rise  immediately  after  labor,  succeeded  by  a  fall  to  or 
below  normal  within  twelve  or  twenty-four  hours.  Baumfelder 
states  that  after  this  fall  there  is  a  gradual  slight  rise,  which  reaches 
its  maximum  on  the  fourth  day.  It  then  remains  constant  for 
two  days,  falling  on  the  evening  of  the  sixth  day  and  rising  during 
the  next  two  days.  All  these  variations  are  very  slight.  On  the 
ninth  day  it  remains  normal. 

Elevations  may  be  caused  by  various  conditions  in  the  early 
puerperium — /.  e.,  errors  in  diet,  constipation,  mental  anxiety,  etc. 
It  is  held  by  many  that  the  filling  of  the  breast  causes  a  rise  before 
the  third  or  fourth  day,  apart  from  pathologic  conditions.  This 
statement  is  misleading.  It  is  possible  that  a  slight  elevation  may 
be  induced  in  this  way,  but  it  is  unimportant  and  often  escapes 
observation.  Too  often  is  a  marked  elevation  attributed  to 
the  milk  when  it  is  due  to  an  infection.  Zweifel  holds  that  an 
axillary  temperature  of  99.5  to  loo^  F.  is  always  pathologic. 
Certainly  such  a  rise  should  always  lead  at  once  to  a  suspicion  of 
infection. 

Pulse. — After  labor  the  pulse  falls  immediately  or  within 
twelve  hours  to  60  or  less.  Rarely  it  may  be  lower  than  40.  The 
explanation  of  the  slow  pulse  has  given  rise  to  much  speculation. 
Blot  thinks  it  due  to  increased  arterial  tension  ;  Lohlein,  to  dis- 
turbed innervation  by  the  altered  constitution  of  the  blood  ;  01s- 
hausen,  to  absorption  of  products  of  degeneration  in  the  uterus ; 
Fritsch,  to  the  mental  and  physical  rest  succeeding  labor.  Schroeder 
thought  that  the  heart  beat  slowly  because  it  had  less  to  do. 
Vejas  believed  it  due  to  increased  vital  capacity  of  the  lungs. 
Swiecicki .  thought  that  the  vagus  was  reflexly  inhibited  as  the 
result  of  chemical  irritation  of  the  uterine  nerves  in  the  process  of 
involution.  Neumann,  who  has  given  the  subject  special  study, 
believes  that  the  bradycardia  is  due  to  stimulation  of  the  cardiac 
inhibitory  fibers,  resulting  from  irritation  of  the  vagus  center  in 
labor.  After  the  second  or  third  day  it  gradually  rises  to  normal. 
The  blood-pressure  is  not  increased,  but  often  may  be  lessened. 
The  rate  is  ea.sily  raised  by  slight  causes.  It  is  important  to  bear 
in  mind  its  elevation  early  in  infective  processes. 

Blood. — Henderson  states  that  during  the  first  few  days  there 
are  changes  in  tlie  size  and  shape  of  the  red  cells,  pointing  to  blood 
regeneration.      He  observed   no    nucleated    red    cells    in   normal 


268  ANATOMY  AND   PHYSIOLOGY. 

cases,  but  only  in  some  pathologic  conditions — /.  c,  syphilis, 
eclampsia — he  noted  several.  After  the  second  day  the  number 
of  red  cells  increased  up  to  the  ninth  day,  as  did  the  percentage  of 
hemoglobin. 

During  the  first  two  or  three  days  of  the  puerperium  there  is  a 
considerable  diminution  in  the  number  of  leukocytes.  Thus,  on 
the  first  day  he  found  the  average  to  be  21,365  per  cubic  milli- 
meter, while  on  the  fourth  day  it  was  13,752  ;  thereafter  there  was 
a  more  gradual  fall.  On  the  eighth  day  it  was  10,147  ;  afterward 
there  was  a  slight  rise.  Hibbard  and  White  have  also  pointed  out 
the  tendency  to  increase  about  the  end  of  the  first  week.  Hender- 
son thinks  that  along  with  the  reduction  in  leukocytes  during  the 
first  few  days,  there  is  as  well  some  leukocytosis.  The  diminution 
in  leukocytes  is  undoubtedly  assisted  by  a  free  lochial  discharge. 
When  the  latter  is  scanty  or  suppressed  the  reduction  may  be  ex- 
pected to  be  less.  The  increased  number  of  leukocytes  may  last 
several  weeks  in  the  puerperium,  though  there  is  no  definite  in- 
formation on  this  point.  In  weak  and  ill-nourished  women  the 
leukocytes  are  greatly  diminished.  Pray  regards  the  persistence 
of  leukocytosis  as  due  to  the  part  they  play  in  effecting  the  in- 
volution of  the  h\'pertrophied  pelvic  organs  and  breasts. 

General  Condition. — After  most  labors  there  is  some  degree 
of  exhaustion  in  the  maternal  system.  Great  variations  are  found, 
depending  on  a  variety  of  factors — /.  c,  the  general  health  of  the 
woman,  her  nervous  organization,  the  difficulty,  duration,  and 
painfulness  of  the  labor,  loss  of  blood,  etc.  Sometimes  there  may 
be  considerable  shock.  Frequently  there  may  be  an  attack  of 
shivering  at  the  end  of  labor  ;  this  is  generall}'  of  nervous  origin, 
but  may  result  from  undue  exposure  of  the  body,  especially  if 
there  has  been  much  perspiration.  In  some  cases  the  woman 
may  remain  in  a  nervous  state  for  some  hours.  Ordinarily,  how- 
ever, there  is  a  tendency  to  sleep. 

After-pains. — During  the  first  few  days  of  the  puerperium 
intermittent  pains  may  be  felt  in  the  lower  abdominal  or  pelvic 
region.  These  are  often  compared  to  modified  labor  pains,  and 
are  usually  due  to  active  contractions  of  the  uterus,  expelling  clots 
that  have  formed  in  its  cavity  ;  they  are  far  more  frequent  in  mul- 
tiparae  than  in  primiparas.  The  formation  of  clots  is  associated 
with  a  tendency  to  undue  relaxation  in  the  uterine  wall.  The 
pains  are  aggravated,  as  a  rule,  when  the  child  is  put  to  the  breast. 
Relief  follows  expulsion  of  the  clots,  though  there  may  be  a 
recurrence  of  the  condition. 

In  some  cases  after-pains  are  present  when  no  clots  are  in  the 
uterus,  the  explanation  being  not  always  certain.  They  may  be 
caused  by  retained  portions  of  the  after-birth.  Sometimes  they 
are  caused  by  traction  of  the  uterus  on  old  inflammatory  tissues. 
Occasionally  bladder  distention  or  tenesmus  may  cause  the  pains. 


RENAL   FUNCTION.  269 

They  must  be  distinguished  from  pain  due  to  a  fresh  inflammatory 
attack  following  infection. 

Renal  Function. — The  excretion  of  urine  is  normally  in- 
creased after  labor.  Winckel  points  out  that  this  is  most  marked 
during  the  first  two  days.  The  increase  is  mainly  in  water,  the 
specific  gravity  being  low,  averaging  10 10.  The  percentage  of 
urea,  phosphates,  and  sulphates  is  lessened,  that  of  sodium 
chlorid  is  not  changed.  During  the  first  day  the  average  is  2025 
c.c.  (74.4  fl.  oz.),  during  the  second  2271  c.c.  (76.5  fl.  oz.).  There- 
after the  total  quantity  is  diminished,  varying  somewhat  from  day 
to  day,  a  return  to  normal  gradually  taking  place.  Albumin  oc- 
casionally appears  in  the  urine  and  disappears,  no  evident  cause 
being  present.  Maguire  states  that  it  is  not  serum  albumin,  but 
globulin.  In  every  case  of  albuminuria  the  possibility  of  definite 
important  causes  should  be  remembered. 

Milk  sugar  is  frequently  found  in  the  urine,  both  when  the 
milk  supply  in  the  breasts  is  abundant  and  when  it  is  failing. 

Grammatikati  has  found  that  the  amount  of  urea  in  the  urine 
increases  with  the  amount  of  milk,  as  do  the  phosphates. 

Fischel  has  demonstrated  the  following  facts  regarding  pep- 
tones. They  are  found  constantly  in  the  urine  in  the  puerperium, 
the  quantity  varying  in  different  cases.  They  appear  after  the 
first  day  and  increase  until  the  fourth,  when  a  gradual  decrease  is 
noted.  As  a  rule,  they  disappear  about  the  twelfth  day.  They 
are  probably  derived  from  direct  conversion  of  the  uterine  muscu- 
lature. In  cases  in  which  peptonuria  has  been  present  before 
labor,  it  is  found  afterward  in  the  early  hours  of  the  puerperium. 
The  length  or  character  of  the  labor  appears  to  have  no  influence 
on  its  production.  After  the  delivery  of  a  dead,  macerated  fetus 
there  is  little  or  no  peptonuria.  The  specific  gravity  of  the  urine 
varies  according  to  the  quantity  of  peptones.  They  are  in  direct 
relationship  to  the  number  of  leukocytes  in  the  blood.  Winckel 
has  reported  a  case  of  Porro's  operation  in  which  peptonuria  was 
absent.  Acetone  is  stated  to  be  constantly  present  in  the  urine 
during  the  puerperium. 


2/0  MANAGEMENT   OF   THE   PUERPERAL    STATE. 

CHAPTER    II. 

MANAGEMENT  OF  THE  PUERPERAL  STATE. 

I/ying-in  Room. — The  patient  should  be  kept  in  a  room 
that  can  be  well  aired  and  lighted.  The  light  should  be  rather 
subdued  for  the  first  few  days.  Ventilation  should  be  arranged 
without  exposure  of  the  woman  to  draughts.  The  temperature 
should  be  about  65°  F.  Quietness  must  be  strictly  enjoined  in 
the  neighborhood  of  the  patient,  and  she  must  be  carefully  pro- 
tected from  unnecessary  incursion  of  visitors.  In  many  cases  the 
accoucheur  must  give  strict  orders  with  regard  to  their  admission. 
The  child  should  not  be  kept  near  enough  to  disturb  her  if  it 
cries.  She  should  not  be  distressed  or  worried  in  any  way.  The 
child  should  not  rest  in  bed  with  the  mother  on  account  of  the 
risk  that  she  may  lie  on  it  in  her  sleep,  and  in  order  that  she 
may  not  be  disturbed  by  it. 

After  the  cleansing  of  the  mother,  following  the  birth  of  the 
child,  the  room  should  be  darkened  and  she  should  be  allowed  to 
rest  quietly  for  a  few  hours.  When  she  feels  faint  or  tired  she 
should  take  a  cup  of  beef  tea  or  chicken  tea,  bouillon,  or  milk 
and  hot  water.  In  cases  of  extreme  nervousness  and  restlessness 
it  may  be  advisable  to  administer  a  soporific — /.  c,  trional,  paral- 
dehyd,  etc. 

After  a  few  hours  the  child  should  be  put  to  each  breast  for  a 
few  minutes.  During  the  first  three  days  the  mother  should  lie 
mainly  on  her  back,  changing  to  her  side  when  she  feels  tired  or 
when  the  child  is  fed.  After  the  first  twenty-four  hours  her  back 
and  head  may  be  somewhat  elevated  with  pillows  for  an  hour  or 
two  each  day  unless  there  is  some  contraindication — /.  e.,  heart 
disease,  marked  anemia,  etc.  She  should  be  enjoined  not  to  raise 
the  body  suddenly  lest  syncope  should  be  caused.  After  three 
days  she  may  be  allowed  to  lie  on  her  back  or  side  at  will. 

In  normal  cases  the  mother  may  be  allowed  to  get  out  of  bed 
between  the  tenth  and  fifteenth  days.  At  first  she  should  remain 
in  a  half-recumbent  posture  on  a  sofa  for  an  hour  or  more,  and 
should  walk  a  little  each  day.  If  the  weather  be  suitable  she 
should  lie  or  sit  out-of-doors  during  the  third  week.  In  the  fourth 
she  may  go  down  stairs,  walk  out-of-doors,  and  take  her  first 
drive.  This  program  may  be  greatly  changed  by  circumstances — 
/.  e.,  in  cases  of  very  difficult  or  exhausting  labors  or  of  marked 
lacerations  the  woman  may  not  be  allowed  out  of  bed  until  during 
or  even  after  the  third  week.  No  fixed  rules  can  be  given.  The 
physician  must  exercise  his  judgment  in  each  case. 

Systematic  general  massage  during  the  lying-in  period  and. 


URINATION— CARE    OF   THE  BOWELS.  2/1 

later,  in  the  puerperium  is  a  valuable  means  of  improving  the 
woman's  general  condition.  Unless  there  is  some  contraindication 
the  woman  may  also  be  allowed  to  take  some  exercise  while  in 
bed.  Bacon  recommends  the  following :  On  the  second  or  third 
day  flexion  and  extension  and  swinging  movements  of  the  upper 
limbs  and  flexion  and  extension  of  the  feet  may  be  carried  out 
each  day  during  the  first  week,  the  duration  varying  according  to 
the  condition  of  the  patient.  At  first  it  should  be  only  a  few 
minutes  ;  later  on  ten  to  fifteen  minutes.  At  the  beginning  of  the 
second  week  flexion  and  extension  movements  of  the  lower  limbs 
may  be  commenced ;  by  the  twelfth  or  fourteenth  day  flexion  of 
the  trunk  on  the  thighs  by  contraction  of  the  muscles  of  the  ab- 
dominal walls.  Resistance  movements  with  apparatus  have  also 
been  recommended. 

Urination. — The  desire  to  urinate  is  feeble  for  many  hours 
after  labor.  In  some  cases  the  woman  may  perform  the  act  nor- 
mally, but  often  she  may  go  twelve  hours  or  more  without  empty- 
ing the  bladder  if  she  be  allowed.  The  practice  of  allowing  her 
to  wait  such  a  period  is  an  unwise  one.  Sometimes  overdistention 
may  be  followed  by  frequent  dribbling,  which  may  be  mistaken 
for  complete  evacuation  ;  the  uterus  is  displaced  and  the  normal 
relationships  disturbed,  favoring  increased  loss  of  blood  in  the 
lochia.  If  the  bladder  be  not  emptied  voluntarily  ten  hours  after 
labor,  the  woman  should  be  encouraged  to  urinate  in  the  bedpan. 
If  she  fail,  a  sterilized  pad  soaked  in  a  hot  antiseptic  solution 
should  be  applied  to  the  vulva,  or  the  solution  should  be  poured 
over  the  vulva.  Sometimes  the  sound  of  running  water  may 
assist  the  woman  to  urinate.  If  these  means  fail  and  the  patient's 
condition  be  good  the  nurse  may  raise  her  nearly  to  the  sitting- 
posture  in  order  that  she  may  be  more  advantageously  placed. 
Only  when  these  methods  are  not  successful  should  the  catheter 
be  employed.  A  boiled  glass  or  silver  instrument  should  be  used, 
and  the  same  thorough  technic  must  be  observed  that  has  been 
described  in  Part  II.,  Chapter  III.  The  quantity  of  urine  passed 
at  each  emptying  of  the  bladder,  during  the  first  twenty-four  hours 
at  least,  should  be  measured.  When  the  quantity  is  small  the 
physician  should  suspect  that  there  is  not  complete  evacuation, 
and  should  examine  the  abdomen  very  carefully  to  determine  the 
condition  of  the  bladder.  After  the  first  urination  the  woman 
should  be  encouraged  to  repeat  the  act  every  five  or  six  hours. 

Care  of  the  Bowels.— If  the  bowels  have  been  thoroughly 
opened  before  labor  they  need  not  be  moved  before  the  third  day. 
To  ensure  that  this  happens,  it  is  well,  as  a  rule,  to  administer  a 
mild  laxative  on  the  evening  of  the  second  day — /.  c,  sodium 
pho.sphate,  citrate  of  magnesia,  or  Hunyadi  Janos  water.  When 
there  is  colic,  castor  oil  with  a  small  dose  of  laudanum  may  be 
given  in  a  capsule  or  in  warm  milk.     On  the  morning  of  the  next 


2/2  MANAGEMENT  OF   THE   PUERPERAL    STATE. 

day  a  movement  may  be  expected.  If  it  does  not  occur,  an 
enema  of  sweet  oil  (oiv)  or  one  of  soapsuds  and  olive  oil  may  be 
given.  During  the  rest  of  the  lying-in  period  these  measures 
may  again  be  required  to  secure  regular  evacuations.  When  the 
woman  is  troubled  with  piles,  aloes  administered  in  half-grain 
doses  night  and  morning  is  very  beneficial. 

Dietary  of  the  Mother. — The  woman  should  be  fed  accord- 
ing to  the  physiologic  requirements.  As  a  rule,  during  the  first 
three  days  she  prefers  liquid  to  solid  food,  as  there  is  usually 
thirst.  She  may  have  at  this  time  milk,  gruel,  bouillon,  weak 
cocoa,  tea,  milk  toast.  During  the  next  few  days  eggs,  fish,  sweet- 
breads, chicken,  rice,  and  cooked  fruits  may  be  gradually  added. 
Thereafter  an  ordinary  simple  dietary  is  allowable,  all  indigestible 
articles — /.  c,  gravies,  pastries,  fancy  puddings,  pickles,  etc.,  being 
avoided.  In  special  circumstances  this  dietary  may  be  changed 
according  to  the  indications. 

Care  of  the  Genitalia. — Immediately  after  the  external 
genitals  have  been  cleansed,  a  dressing  of  sterilized  wool  or  gauze 
should  be  applied  to  the  vulva  and  fastened  to  the  abdominal 
binder.  During  the  first  six  or  eight  hours  this  should  be  changed 
every  two  hours  ;  afterward  ever}^  three  or  four  hours  during  the 
first  five  days,  according  to  the  degree  of  soiling ;  thereafter  less 
frequently.  Four  times  daih',  at  least,  when  the  dressing  is 
changed,  the  external  genitalia  should  be  well  washed  with  one 
of  the  antiseptic  lotions  already  mentioned,  sterile  wool  being 
used  for  the  purpose.  If  there  has  been  much  bruising  and 
tearing  of  the  vulva,  or  if  there  be  any  doubts  as  to  the  cleanli- 
ness of  the  parts,  it  is  advisable  to  apply  gauze  dressings,  soaked 
in  the  antiseptic  solution,  continuousl}'for  four  or  five  days,  instead 
of  dry  dressings. 

As  regards  the  use  of  the  vaginal  douche  in  the  puerperium 
there  has  been  much  discussion,  the  groundwork  of  w4iich  has 
already  been  stated.  (See  p.  iii.)  Though  the  last  word  has 
not  been  stated,  it  must  be  conceded  that  if  the  parturient  woman 
be  healthy,  presenting  no  signs  of  an  infective  process  in  her 
genitalia,  and  if  her  labor  be  conducted  with  strict  asepsis,  anti- 
septic douching  is  not  a  necessity  in  the  puerperium.  But  if  this 
scientific  position  is  to  be  sustained,  the  strictest  care  must  be  ex- 
ercised in  the  care  of  the  external  genitals  and  in  the  avoidance 
of  contamination  after  labor.  If  this  be  not  done,  there  is  always 
danger  that  infective  organisms  may  develop  in  torn  tissues  or  in 
the  blood-clot  that  tends  to  collect  in  the  vagina  as  a  result  of  the 
dorsal  posture  so  universally  adopted  in  civilized  countries.  Many 
patients  prefer  to  be  douched  and  feel  better  afterward  because 
their  tastes  are  satisfied  with  regard  to  cleanliness.  There  is  no 
objection  to  the  use  of  warm  sterile  water  or  saline  solution  as  a 
daily  vaginal  douche,  provided  the  external  genitals,  the  douching 


THE   NEWBORN  CHILD   AND   ITS  MANAGEMENT.        273 

apparatus,  and  the  nurse's  hands  be  thoroughly  cleansed.  It  has 
been  clearly  demonstrated  that  a  douche  tube  cannot  be  passed 
into  the  vagina,  if  the  vulva  be  dirty,  without  introducing  micro- 
organisms. 

Antiseptic  douching  should  be  carried  out  in  the  early  puer- 
perium  after  labors  in  which  there  has  been  a  failure  to  employ 
rigid  asepsis  during  labor,  or  when  there  is  evidence  that  the 
genital  tract  has  recently  been  the  seat  of  an  infective  process. 
The  antiseptic  douche  may  be  given  twice  daily  for  five  days  (or 
longer) ;  thereafter,  once  a  day  for  a  week  or  two.  The  tube  and 
reservoir  should  be  sterilized  before  use,  and  when  not  in  use  should 
be  covered,  so  that  dust  cannot  enter.  The  nozzle  that  enters  the 
vagina  should  be  of  glass,  ten  inches,  at  least,  in  length,  and  should 
be  boiled  for  eight  minutes  in  weak  soda  solution  each  time  before 
it  is  used.  The  nurse  should  cleanse  her  hands  as  if  preparing  for 
a  surgical  operation  before  administering  the  douche.  The  greatest 
cleanliness  is  obtained  if  she  wears  rubber  gloves  that  have  been 
sterilized  by  boiling  in  plain  water  for  ten  minutes.  She  should 
hold  the  nozzle  near  its  outer  end  with  one  hand,  and  with  the 
other  separate  the  cleansed  labia  as  she  introduces  the  point.  As 
the  lotion  runs  the  nurse  should  take  care  that  there  is  a  free 
return  flow  and  that  no  distention  of  the  vasfina  be  caused. 


CHAPTER    III. 
THE  NEWBORN  CHILD  AND  ITS  MANAGEMENT. 

As  soon  as  the  child  is  born,  attention  should  be  given  to  its 
respiration  before  the  cord  is  divided.  If  it  does  not  breathe  freely 
at  once,  a  finger  covered  with  sterile  gauze  should  be  inserted  into 
the  mouth,  in  order  to  wipe  out  any  mucus  and  blood  that  may 
be  in  the  mouth  or  pharynx.  The  nose  should  also  be  wiped. 
To  stimulate  respiration  the  child  may  be  held  up  by  the  feet, 
the  face  or  body  may  be  slapped,  cold  water  may  be  sprinkled  on 
it,  or  one  may  blow  on  its  face.  The  methods  to  be  followed  in 
cases  of  asphyxia  are  described  later  (p.  626). 

The  eyes  should  be  well  washed  out  with  normal  saline  solu- 
tion. Whenever  there  is  any  possibility  that  they  may  have  been 
contaminated  in  the  maternal  canal,  a  solution  of  protargol  (10 
per  cent.),  nitrate  of  silver  (2  per  cent.),  or  corrosive  sublimate  (i 
or  2  grains  to  the  pint)  should  be  dropped  into  them  as  early  as 
possible  after  birth. 

Ligation  of  the  cord  has  already  been  discussed  (Part  IL,  Chap- 


274         THE   XEIVBORN  CHILD   AXD   ITS  MANAGEMENT. 

ter  III.).  The  stump  should  be  wrapped  in  aseptic  gauze ;  it  is  not 
necessary  to  apply  powder  or  oil  to  it.  Thus  dressed  the  stump 
is  laid  flat  on  the  belly,  and  kept  in  position  by  an  abdominal 
binder.  The  stump  usually  separates  in  four  to  seven  days, 
leaving  a  small  moist  area  at  the  navel ;  this  should  be  kept 
dry  with  boric  acid  and  covered  with  sterile  gauze  until  satis- 
factorily healed. 

Cleansing  the  Child. — The  child  must  be  cleansed  in  a 
well-warmed  room.  In  normal  cases  it  should  be  rubbed  with 
sweet  oil  or  vaselin  in  order  to  remove  the  vernix  caseosa,  and 
afterward  wiped  with  a  soft,  clean  cloth.  Then  it  may  be  washed 
in  water  at  a  temperature  of  95°  F.,  mild  soap — /.  r.,Unna's  super- 
fatted or  white  castile,  being  employed.  Strong  soap  is  apt  to 
irritate  the  conjunctivae.  The  skin  is  then  dried  with  a  soft,  warm 
cloth,  and  aftenvard  covered  with  dusting-powder — /.  c,  borated 
talc  or  a  mixture  of  starch  and  talc.  In  succeeding  washings,  if 
soap  irritates  the  skin,  a  muslin  bag  containing  oatmeal  may  be 
used  as  a  substitute.  When  the  child  is  weak  at  birth  or  if  it  has 
been  much  exposed,  it  should  be  warmed  in  a  dish  of  water  at  a 
temperature  of  100°  F.,  then  wrapped  in  blankets  and  placed  near 
a  fire  or  hot-water  bag.  The  first  cleansing  need  not  be  carried 
out  for  several  hours.  At  the  time  of  washing  a  careful  exami- 
nation should  be  made  to  see  if  an}-  malformation  exists.  When 
the  first  visit  is  made  after  the  labor,  inquiry  should  be  made  as 
to  the  empt}'ing  of  the  bladder  and  rectum. 

Clothing. — After  the  cleansing  the  child  should  be  dressed. 
The  abdominal  binder  may  be  soft  flannel  in  winter  and  light 
merino  in  summer.  Outside  of  this  the  clothing  should  be  warm 
and  loose,  not  interfering  with  respiration  nor  with  the  movements 
of  the  hands  and  feet.  During  sleep  a  light  shawl  may  be  used 
to  cover  the  sides  of  the  head,  neck,  and  shoulders. 

Nursing. — The  mother  should  always  nurse  her  child  unless 
there  be  contraindications.  About  six  hours  after  labor  it  should 
be  put  to  each  breast  for  two  or  three  minutes.  This  practice 
should  be  repeated  every  four  hours  during  the  day  until  milk  has 
abundantly  appeared  in  the  breasts.  The  infant  in  this  way  be- 
comes accustomed  to  sucking,  which  acts  also  beneficially  in 
stimulating  the  mammary  tissue  and  the  uterus.  The  colostrum 
that  may  be  withdrawn  has  a  laxative  effect  on  the  infant's  bowels. 
If  there  is  a  special  reason  for  not  putting  the  child  to  the  breast 
for  the  first  two  or  three  days,  the  child  should  be  given  a  teaspoon- 
ful  of  warm  sterile  water  at  inter\'als.  W'hen  the  milk  secretion 
is  well  established,  nursing  should  be  carried  on  with  as  much 
regularity  as  possible.  At  first  the  infant  may  be  fed  every  two 
hours  during  the  day  and  once  during  the  night.  If  the  milk  be 
plentiful  the  duration  of  suckling  should  be  about  fifteen  minutes, 
and  the  breasts  should  be  used   alternately.     If  the  milk  be  not 


NURSING.  275 

very  abundant  both  may  require  to  be  suckled  at  each  feeding. 
The  night  interval  should  be  gradually  increased  as  the  infant 
grows,  until  at  the  sixth  month  there  should  be  no  feeding  be- 
tween 10  P.  M.  and  5  A.  M.  The  day  intervals  should  also  be 
gradually  increased,  until  by  the  sixth  month  the  infant  needs  to 
be  nursed  only  five  or  six  times  in  twenty-four  hours.  Too  fre- 
quent feeding  is  apt  to  upset  the  infant's  digestion.  The  mother 
must  be  taught  to  refrain  from  feeding  the  child  whenever  it  cries. 
Irregular  feeding  is  also  productive  of  disorder.  The  nipples 
should  be  cleansed  after  each  feeding  with  boric  lotion  and  sterile 
water,  being  dried  with  sterile  absorbent  cotton  ;  rubbing  is  not 
necessary.  If  the  nipples  are  sore  or  cracked  they  should  be 
anointed  with  sterile  vaselin  or  cocoa  butter. 

When  the  infant  hurts  the  nipple  a  nipple  shield  may  be  worn 
to  give  relief.  In  extreme  cases  it  may  be  necessary  to  use  a 
breast  pump,  the  milk  being  afterward  given  to  the  infant.  In 
very  tender  states  of  the  nipples  the  application  of  lead  and  opium 
lotion  after  nursing  gives  much  relief;  but  it  must  be  carefully 
washed  away  before  the  infant  is  again  put  to  the  breast.  When 
the  breasts  are  uncomfortably  distended  a  compressing  or  sus- 
pensory bandage  may  be  worn.  Sometimes  in  these  cases  it  may 
be  necessary  to  draw  off  some  milk  with  the  pump  in  addition  to 
that  which  the  infant  takes  ;  or  the  nurse  may  carefully  massage 
the  breasts  with  clean,  oiled  fingers. 

Ordinarily  the  breast  is  rubbed  from  the  periphery  to  the  nipple. 
Bacon  advises  against  this  method,  stating  that  the  fulness  in  the 
breasts  is  more  due  to  overdistended  blood-  and  lymph-vessels 
than  to  accumulation  of  milk.  He  recommends,  therefore,  rub- 
bing the  surface  outside  and  above  the  breasts  in  the  direction  of 
the  venous  and  lymph  flow  toward  the  axillary  and  subclavian 
trunks  ;  afterward  the  breasts  are  gradually  encroached  on. 

If  the  infant  be  too  weak  to  suck  the  milk  may  be  withdrawn 
by  a  pump  and  administered  with  a  spoon.  If  the  infant  appears 
restless  and  unsatisfied  after  successive  feedings  the  milk  should 
be  examined  chemically  and  microscopically.  In  such  cases  the 
mother's  health  must  be  carefully  investigated  and  all  irregularities 
corrected.  It  must  always  be  remembered  that  the  breasts  may 
excrete  as  well  as  secrete,  and  that  drugs — /.  e.,  opium,  belladonna, 
etc.,  may  thus  enter  the  milk  and  affect  the  infant. 

When  the  milk  is  poor  the  dietary  of  the  mother  should  be 
altered  ;  very  often  an  increase  in  milk  and  eggs  will  improve  the 
mammary  secretion.  Sometimes  malt  liquors,  maltine,  or  malted 
milk  is  necessary.  .  In  the  dietetic  measures  adopted  the  mother's 
digestion  must  not  be  upset.  When  the  quantity  of  milk  is  in- 
sufficient, accessory  artificial  feeding  must  be  carried  out,  the 
infant  must  be  weaned,  or  a  wet-nurse  employed.  In  cases  where 
the  infant  does  not  nurse,  it  is  necessary  to   check  the  mammaiy 


2/6        THE   NEWBORN  CHILD   AND   ITS  MANAGEMENT. 

secretion  with  as  little  disturbance  to  the  mother  as  possible.  To 
accomplish  this  she  should  take  a  minimum  quantity  of  liquids  in 
her  diet  and  should  keep  the  bowels  well  opened.  A  compressing- 
bandage  should  be  applied  to  the  breasts.  In  some  cases  it  is 
necessary  to  administer  atropin  or  potassium  iodid  internally,  or 
belladonna  ointment  or  plaster  locally  to  the  breasts. 

In  certain  conditions  the  infant  should  not  nurse — /.  c,  mastitis  ; 
depressed,  deformed,  or  badly  cracked  nipples  ;  tuberculosis, 
syphilis,  rheumatism,  sepsis,  bad  cardiac  or  renal  disease,  marked 
anemia,  chronic  skin  diseases,  and  various  nervous  diseases. 

If  menstruation  appears  during  the  nursing-period  the  infant 
may  not  be  affected  by  it.  Sometimes  its  digestion  is  upset  and 
artificial  feeding  may  be  necessaiy.  If  the  flow  becomes  excessive 
or  irregular  it  is  advisable  to  wean  the  child,  since  the  mother's 
health  is  likely  to  suffer  by  the  excessive  drain  on  her  system. 

If  the  nursing  mother  becomes  pregnant  the  child  should  be 
weaned. 

I/actation. — At  the  beginning  of  the  puerperium  the  breasts 
contain  colostrum,  a  white  or  whitish-}'ellow,  viscid  fluid,  some- 
what resembling  milk,  but  being  richer  in  sugar,  fat,  and  salts  ;  it 
contains  characteristic  "  corpuscles  "  that  are  epithelial  cells  filled 
with  fat  globules.  It  coagulates  on  boiling,  due  to  the  presence 
of  a  special  form  of  proteid.  The  fat  globules  are  less  uniform  in 
size  than  those  of  milk,  and  the  corpuscles  are  four  or  five  times 
as  large  as  milk  globules. 

Woodward  gives  the  following  average  of  several  specimens 
of  colostrum  : 

Specific  gravity 1024  to   1034  ^ 

Water 87.5  percent. 

Proteid I.9    "      " 

Fat 4.0    "       <' 

Sugar 6.5    "       " 

Mineral  matter 0.2    "       " 

Considerable  variations  are  found  by  different  observers  as  re- 
gards the  percentage  of  proteids.  During  a  week  or  more  colos- 
trum corpuscles  may  be  found  in  the  milk  in  gradually  diminishing 
numbers.  The  true  milk  secretion  begins  usually  on  the  third 
day,  often  on  the  second,  sometimes  on  the  first,  occasionally  on 
the  fourth  or  fifth  day.  In  some  cases  it  may  not  appear  at  all. 
The  breasts  at  this  time  become  more  sensitive,  being  firmer  and 
larger,  these  changes  varying  much  in  different  cases. 

The  woman  may  be  nervous  and  restless  as  the  breast  phe- 
nomena develop,  and  the  condition  may  be  aggravated  by  the 
child's  attempts  at  nursing.  Sometimes  these  disturbances  may 
cause  a  slight  rise  in  temperature  for  several  hours.     This  must 

^  Variations  are  due  to  different  quantities  of  fat. 


LACTAl'ION.  2^] 

be  carefully  distinguished  from  febrile  states  due  to  actual  infec- 
tion. The  "  milk  fever "  described  by  the  older  authors  is  in 
reality  an  infection  fever. 

The  quantity  of  milk  secreted  varies  greatly  in  different  women. 
During  the  first  three  days  the  whole  quantity  is  between  50  and 
200  c.c.  At  the  end  of  the  first  week  the  daily  secretion  amounts 
to  about  400  c.c. ;  at  the  end  of  the  second  week  about  ^  to  2 
liters.  Variations  depend  on  a  number  of  factors — i.  e.,  the  size 
and  activity  of  the  breasts,  the  amount  of  fluid  taken  into  and 
discharged  from  the  system.  When  a  woman  does  not  nurse  her 
child  the  secretion  generally  ceases  in  two  or  three  weeks  and  the 
breasts  atrophy,  though  for  a  considerable  time  afterward,  in  some 
cases,  a  small  amount  of  fluid  may  be  squeezed  from  the  nipple. 

The  characters  of  normal  milk  are  as  follows  :  It  is  a  sHghtly 
alkaline  fluid,  1024  to  1035  specific  gravity,  being  an  emulsion  of 
minute  oil  globules  in  a  colorless  plasma.  The  latter  is  derived 
from  the  blood,  and  holds  in  solution  milk  sugar  and  morganic 
salts.  The  fats,  sugar,  and  proteids  are  derived  from  the  cells  of 
the  acini  of  the  glands.  Many  diflerences  are  observed  in  the 
records  of  milk  analyses,  due  to  variations  in  the  technic  and  in 
the  composition  of  different  specimens.  One  of  the  most  im- 
portant recent  records  is  that  of  Camerer  and  Soldner,  who  give 
the  following  analysis  of  milk  during  the  second  week  of  nursing : 

Water 87.75  per  cent. 

Solids 12.25 

Proteids 1.62 

Fat       „     3. 14 

Milk  sugar 6  62 

Mineral  matter  , 0.27 

Citric  acid 9.05 

Unknown  extractives 091 

Attention  is  to  be  drawn  to  the  unknown  extractives  contain- 
ing nitrogen.  These  formerly  were  classed  as  proteid  material, 
which  accordingly  bulked  as  a  larger  quantity  in  the  older  anal- 
yses. The  proteids  and  mineral  matter  tend  to  lessen  in  amount 
as  lactation  advances,  the  sugar  increasing  rapidly  up  to  the  end 
of  the  second  week,  and  afterward  at  a  slower  rate  ;  the  fat  reaches 
its  highest  percentage  during  the  second  month,  falling  off  after 
this  period. 

These  points  are  shown  in  tables  of  Camerer  and  Soldner : 

Period,  .Total 

nitrogen 

5th  day 0-33 

8th  to  nth  day 0.27 

20th  to  40th  day 0.20 

70th  to  1 20th  day 0.17 

170th  and  after 0.14 


roteid. 

Fat. 

Sugar. 

Ash. 

2.0 

2.8 

5-4 

034 

1.6 

31 

6.2 

0.27 

I.I 

3-8 

6.4 

0.22 

I.O 

2.9 

6.7 

0.20 

0.8 

2.6 

6.8 

0.19 

278        THE  NEWBORN  CHILD  AND  ITS  MANAGEMENT. 

It  is  interesting  to  compare  this  change  in  milk  with  the  in- 
crease in  the  daily  weight  of  the  child.  Proscher  shows  that  the 
average  daily  increase  in  weight  is  35  to  40  gm.  during  the  first 
six  weeks,  a  decrease  taking  place  afterward,  until  at  the  sixth 
month  it  amounts  to  about  18  gm.  During  the  first  few  weeks  the 
child  grows  much  faster  than  afterward  and  requires  relatively 
more  building  material ;  hence  the  abundant  nitrogenous  and 
mineral  elements  in  the  early  period.  The  after  gradual  increase 
in  carbohydrates  is  related  to  the  growing  muscular  activity.  It 
is  evident  from  the  latter  that  milk  does  not  get  richer  as  the  child 
grows  older ;  this  defect  is  made  up  by  the  greater  quantity  taken 
by  the  infant. 

The  variations  found  in  the  milk  of  a  nursing  woman  from 
time  to  time  are  not  always  explainable.  They  may  sometimes 
be  more  marked  than  those  found  on  comparing  the  milk  of  dif- 
ferent women  at  the  same  period  of  lactation.  Baumm  and  Illner 
have  emphasized  the  fact  that  the  composition  of  milk  is  markedly 
independent  of  outside  influences.  Weakness,  various  diseases, 
pregnancy,  and  emotional  conditions,  as  a  rule,  afiect  it  inappre- 
ciably. Menstruation  rarely  alters  the  milk  so  as  to  disturb  the 
child.  These  observers  have  clearly  shown  that  a  feeble  child 
does  not  necessarily  mean  poor  milk.  On  the  contrary,  they 
found  that  in  such  cases  the  milk  was  usually  richer.  They 
analyzed  milk  produced  during  various  dietaries,  and  found  that 
on  the  whole  fat  was  the  only  element  in  the  milk  that  was  appre- 
ciably affected  by  the  diet.  It  was  increased  only  when  an 
abundant  ordinaiy  mixed  diet  or  a  highly  nitrogenous  diet — /.  e., 
one  with  much  cheese,  eggs,  and  meat,  was  given. 

Abundant  carbohydrates  did  not  increase  the  fat,  nor  did  fat 
taken  in  the  diet ;  indeed,  increase  of  the  latter  was  usually  ac- 
companied by  a  diminution  of  that  in  the  milk.  Increase  of  fluids 
consumed  caused  no  appreciable  increase  in  the  quantity  of  the 
milk.  It  is  thus  evident  that  the  composition  of  milk  is  largely 
independent  of  diet.  Even  though  the  food  be  largely  dimin- 
ished, milk  is  produced  at  the  expense  of  the  maternal  tissues. 
Alcoholic  beverages  do  not  directly  affect  the  quality  of  the  milk. 
Too  frequent  suckling  tends  to  cause  increased  richness  of  the 
milk,  and  it  may  become  less  digestible  and  thus  affect  the  child. 

Substitute  Feeding. — Wet=nursing. — When  a  good  reason 
exists  for  not  feeding  the  child  from  the  mother's  breasts,  the 
best  substitute  is  to  use  another  nursing  woman.  In  practice  it  is 
not  often  possible  to  obtain  a  thoroughly  suitable  wet-nurse.  In 
selecting  one  the  physician  must  exercise  great  discretion.  The 
woman  should  not  be  too  young,  twenty-one  to  twenty-six  being 
the  best  age.  She  should  be  healthy  and  free  from  tuberculosis, 
syphilis,  or  any  other  taint.  Her  own  child  should  be  examined 
and  found  free  from  disease  ;  its  age  should  be  as  near  as  possible 


INFANT  INCUBATION. 


279 


that  of  the  one  to  be  nursed.  The  wet-nurse's  habits  as  regards 
diet,  exercise,  etc.,  must  be  carefully  regulated. 

Mixed  Feeding. — In  some  cases  the  mother  is  unable  to 
supply  all  the  milk  necessary  for  her  child,  an  additional  quantity 
of  artificial  milk  being  needed.  The  latter  may  be  given  two  or 
more  times  during  the  twenty-four  hours.  The  mother  should  be 
regular  in  her  hours  of  nursing. 

Artificial  Feeding. — Frequently  it  is  necessar>'  to  nourish  the 
infant  entirely  on  artificial  food.     Within  recent  years  this  system 


Fig.    133. — Incubator   of  the   system   established   at  the  Chicago   Lying-in   Hospital 

(De  Lee). 


has  been  greatly  improved  and  very  satisfactory  results  have  been 
obtained.  (For  full  information  works  on  Infant  Feeding  should 
be  consulted.) 

Infant  Incubation. — In  many  cases  infants  are  born  with 
such  enfeebled  vitality  that  special  care  must  be  taken  to  rear 
them.  For  this  purpose  the  incubator  is  of  great  value.  At  the 
present  time  there  are  differences  of  opinion  as  to  the  extent  to 
which  this  apparatus  should  be  employed,  but  the  following  indi- 
cations given  by  De  Lee  may  be  observed : 


28o 


THE   NEWBORN  CHILD   AND   ITS  MANAGEMENT. 


1.  PreniatU7-ity  or  Small/icss. — All  infants  born  earlier  than 
three  weeks  before  term,  and  all  which  do  not  weigh  more  than 
five  pounds  at  birth,  should  be  placed  in  the  incubator. 

2.  Congenital  Weakness. — Full-time  infants  of  low  vitality,  as 
indicated  by  subnormal  temperature,  cyanosis,  tendency  to  scle- 
rema or  edema,  should  be  treated  as  though  premature. 


^ 


^^>- 


ipv 


JL 


^ ' 


"-^^-yr---^--^-^ 


g 


Oi 


Fig.  134. — Diagrammatic  section  of  incubator  system  in  Chicago  Lying-in  Hos- 
pital (De  Lee):  a.  Pipe  bringing  air  from  outside;  b,  damper;  c,  cotton  filter  ;  g, 
water-pan;  h,  flue  conducting  air  into  bed-chamber;  /,  bed;  /,  escape  flue;  m,  chim- 
ney; ;/,  anemoscope;  o,  ethyl  chlorid  discs;  /,  lever;  q,  cover  of  air-flue;  r,  hot-water 
boiler ;  v,  gas-burner. 


3.  Shoek  following  difficult  labors,  asphyxia,  various  diseased 
conditions. 

4.  Hcinorrliagic  diathesis — /.  e.,  melena,  morbus  maculosus 
Werlhofii,  etc. 

The  infant  should  be  placed  in  the  incubator  at  the  earliest 
moment  after  birth,  to  get  the  greatest  benefit. 

Various  forms  of  incubators  have  been  devised.  A  good  one 
should  be  simple  in  construction  and  should  be  capable  of  easy 
cleansing.     It  should  provide  for  the  continual  admission  of  fresh 


INFANT  INCUBATION.  28 1 

air  properly  heated  and  moistened.  One  of  the  most  satisfactory 
known  to  the  author  is  that  devised  by  De  Lee  and  used  in  the 
Chicago  Lying-in  Hospital.  It  consists  of  a  box  29  in.  high,  22 
in.  deep,  and  20  in.  wide  ;  it  has  two  compartments — a  lower,  con- 
taining a  water  pan,  and  an  upper  for  the  infant,  which  rests  on  a 
cotton  mattress  swinging  in  a  basket.  The  compartments  are 
connected  by  air  flues  only.  There  are  doors  in  the  front,  through 
which  the  infant  is  handled,  and  one  at  the  side,  through  which  it 
is  observed  and  fed. 

The  heating-system  consists  of  the  water  pan  inside  the  box, 
near  the  floor,  connected  with  an  outside  boiler. 

The  air  is  kept  at  86°  to  93°  F.,  and  the  bed  of  the  infant  at 
94°  to  100°  F.  There  is  an  automatic  regulator  attached  to  the 
box.  It  consists  of  three  biconvex  hollow  disks  containing  ethyl 
chlorid,  which  expand  and  contract  with  heat  and  cold;  these  are 
placed  in  the  upper  chamber,  and  are  connected  by  a  lever  system 
with  a  movable  cover  on  the  air  flue  of  the  hot-water  boiler. 
When  the  incubator  cools  the  hollow  disks  contract,  the  cover 
falls,  the  hot  air  is  confined,  the  water  is  heated,  and  the  tempera- 
ture rises.  When  the  incubator  gets  too  hot  the  disks  expand, 
the  cover  rises,  and  the  hot  air  escapes  from  the  flue,  and  the 
temperature  falls.  The  gas  burner  that  furnishes  the  heat  is  pro- 
vided with  a  pressure  regulator  to  ensure  a  steady  supply.  The 
admission  of  cold  air  to  the  lower  chamber  is  regulated  by  a 
damper.  The  air  passes  from  outside  the  house  to  the  incubator 
in  a  three-inch  pipe  ;  it  is  filtered  through  cotton  at  the  side  of 
the  lower  chamber  and  passes  under  the  water  pan.  As  it  is 
heated  it  rises  through  a  flue  and  enters  the  upper  chamber  where 
the  infant  lies.  It  escapes  by  another  flue,  the  lower  end  of  which 
is  placed  below  the  level  of  the  bed,  and  the  upper  end  forms  a 
chimney  placed  above  the  box.  Above  the  latter  is  an  exhaust 
flue  with  a  funnel,  which  creates  a  current  toward  the  ceiling  and 
tends  to  prevent  strong  down  draughts  from  entering  the  incubator 
chimney. 

Moisture  is  supplied  by  a  dish  of  water  and  a  wet  screen  placed 
internal  to  the  cotton  filter.  A  Mason  hygrometer  is  placed  in 
the  bedchamber  to  determine  humidity. 

Most  of  the  incubators  in  use  are  simpler  in  construction  than 
the  above.  Auvard's  form  is  a  wooden  box  heated  by  cans  of 
water,  with  an  opening  for  air  at  the  bottom,  a  vent  at  the  top, 
and  a  sliding  glass  cover.  The  air  is  moistened  with  a  wet  sponge. 
Such  incubators  are  very  imperfect  and  do  not  allow  of  the  ad- 
mis.sion  of  fresh,  uncontaminated  air.  They  may,  however,  serve 
to  transport  weak  and  premature  infants  from  private  houses  to  a 
hospital,  where  a  proper  stationary  incubator  maybe  used. 

Care  of  the  Infant. — The  temperature  in  the  bedchamber 
should  be  on  the  average  89°  F.     When  the  infant  is  very  weak 


282 


THE   NEWBORN  CHILD   AND   ITS  MANAGEMENT. 


it  should  be  a  degree  or  two  higher.  The  temperature  may  be 
reduced  graduall}-  to  82°  F. 

The  moisture  may  also  be  regulated  by  altering  the  size  of  the 
wet  screen  or  the  amount  of  water  in  the  dish.  The  range  of 
humidity  is  ordinarily  from  35  to  50  per  cent.  De  Lee  states 
that  the  moisture  must  be  increased  the  more  puny  and  weak  the 
infant. 

The  dress  should  be  woollen,  simply  and  loosely  made,  so  that 
it  may  easily  be  changed. 

As  regards  the  diet,  there  can  be  no  doubt  as  to  the  great 
value  of  mother's  milk  for  incubator  infants.  Indeed,  according 
to  De  Lee,  it  is  almost  impossible  to  raise  them  satisfactorily  or 
at  all  without  it.  Mixed  feeding  is  the  next  best  method.  The 
frequency  and  amount  of  the  feedings  are  regulated  by  the  size 
and  vitality  of  the  infants. 

Planchon  gives  the  following  tables : 

For  Infants  Weighing  Ltss' than  1800  Grams  (3  lbs.  12  oz.). 

Every  hour  about — 

First       day 63  gm.  2  oz.  \  dr.             45  drops. 

Second  " 127  "  4  "  I    "              75 

Third      " 151  "  5  "                             2i  dr. 

Fourth    " 200  "  6i  "                              2 

Fifth       " 224  "  7"  "  2  dr.               2  "       .15  1U 

Sixth       " 230  "  7  "  4    "                 2\  " 

Seventh  " 263  "  8.V  "                              2  "        .45  TTl 

Eighth    " 281  '•  9  "                            3  " 

Ninth      " 303  '•  10  "                              Z\  " 


For  Infants  Weighing  from  1800  to  2200  CJrams  (3  lbs.  12  oz.  to  4  lbs.  9  oz. 

Every  hour  about — 


First  day 
Second  " 
Third  " 
Fourth  ' ' 
Fifth  " 
Sixth  " 
.Seventh  " 
Eighth  " 
Ninth     " 


120  gm. 

4  oz 

173  " 

5^  " 

247  " 

8  " 

281  " 

9  " 

312  " 

10  " 

347  " 

II 

364  " 

II  " 

393  " 

12  " 

404  " 

13  " 

2  dr. 


75 
■'1 

2.\ 
3' 

3l 

J4 

4 

44 

4^ 


drops, 
dr. 


For  Infants  Weighing  from  2200  to  2500  Grams  (4  lbs.  9  oz.  to  5  lbs.  40Z.). 

Every  hour  about — 

First       day 153  gm.     5    oz.  \\  dr. 

Second  " 266    "       8    "  5    dr.  3      " 

Third      " 299    "      10    "  Z\    " 

Fourth    " 341    "      II     "  3I    " 

Fifth       " 365    "     II    "  7    dr.  4      " 

Sixth      " 390    "     12    "  5     '*  4l    " 

Seventh" 400    "      13    "  A\    " 

Eighth    " 413    "     13     "  3    dr.  \%    " 

Ninth     " 418    "     13     "  4    "  5      " 


INFANT  INCUBATION.  283 

Overfeeding  must  be  avoided.  When  the  infant  can  suck  and 
swallow  a  small  vial  with  a  nipple  is  used ;  w  hen  it  cannot  the 
fluid  may  be  introduced  through  the  mouth  or  nose  with  a  medi- 
cine dropper. 

When  sufficient  food  cannot  be  given  in  this  way  gavage  may 
be  employed,  a  catheter  being  passed  into  the  stomach  and  the 
fluid  poured  in.  Plenty  of  water  must  be  administered.  When 
it  is  difficult  to  give  enough  by  the  mouth,  normal  saline  solution 
maybe  injected  at  intervals  into  the  bowel.  During  the  early 
days  the  infant  should  remain  in  the  incubator  while  being  fed. 
As  it  gets  stronger  it  may  be  lifted  out  into  the  warm  room. 

The  infant  should  not  be  bathed  at  first,  but  should  be  anointed 
daily  with  sweet  oil  or  benzoated  lard.  During  the  second  week, 
if  the  infant  thrives,  it  may  be  bathed  in  a  hot  room,  in  water  at  a 
temperature  of  102°  F.  Each  day  massage  and  passive  move- 
ments must  be  carried  out  with  care  and  gentleness.  The  rectal 
temperature  should  be  taken  morning  and  evening,  and  a  record 
of  the  infant's  weight  kept.  The  infant's  position  in  its  bed  should 
be  changed  from  time  to  time. 

The  period  of  incubation  varies  usually  from  a  few  days  to  a 
month,  but  sometimes  may  be  prolonged  beyond  this  period.  Its 
removal  depends  upon  the  circulation  of  the  infant  and  its  power 
to  maintain  its  body  temperature.  As  the  infant  grows  stronger 
the  temperature  of  the  incubator  may  be  gradually  reduced  to 
82°  F.,  and  later  to  the  temperature  of  the  room  in  the  daytime, 
the  heat  being  turned  on  somewhat  at  night.  Full-time  infants 
which  have  suffered  from  shock  need  only  be  kept  in  the  chamber 
until  they  have  recovered. 


PART  IV. 

THE  PATHOLOGY  OF  PREGNANCY. 


Under  this  heading  are  considered  the  most  common  diseased 
conditions  that  compHcate  pregnancy.  Many  of  these  morbid 
processes  run  a  course  in  no  way  different  from  that  noticed  in 
the  non-pregnant  condition  ;  some  are  considerably  modified  by 
pregnancy.  Several  diseased  conditions  are  entirely  due  to  causes 
associated  with  the  gravid  state.  Many  of  these  affections  pro- 
foundly influence  the  course  and  duration  of  the  gestation  and  the 
health  of  the  mother. 


CHAPTER    I. 

TOXEMIA  OF  PREGNANCY. 

Within  recent  years  an  increasing  amount  of  attention  has 
been  given  to  the  influence  of  toxic  matters  accumulated  in  the 
body  of  the  pregnant  woman  as  a  factor  in  producing  many  of  the 
disturbances  described  under  the  Pathology  of  Pregnancy.  At 
the  present  time  the  subject  is  still  in  the  speculative  stage.  The 
nature  of  the  toxic  materials  and  the  variations  in  the  toxicity 
of  the  blood  and  excreta  are  not  known  with  any  certainty  ;  in  the 
chapter  on  Eclampsia  I  have  given  an  account  of  various  ex- 
periments to  determine  these. 

Poisonous  matters  in  the  body  arise  from  various  sources. 
They  are  produced  as  the  result  of  all  cell-activity  both  in  the 
mother  and  the  fetus.  In  pregnancy  metabolic  changes  are  more 
marked  than  in  the  non-pregnant  state,  and  increased  waste  ma- 
terial is  produced  from  the  combined  metabolism  of  the  mother 
and  the  fetus.  Various  toxic  salts,  extractives,  etc.,  are  eaten  with 
the  food.  Many  poisonous  substances  are  produced  in  the  ali- 
mentary canal  in  connection  with  digestion  and  as  the  result  of  the 
action  of  micro-Organisms.  These  toxic  agents  are  continuously 
eliminated  from  the  body  by  the  lungs,  skin,  kidneys,  and  intes- 
tine, or  destroyed  in  various  methods  that  are  not  yet  well  under- 

284 


TOXEMIA    OF  PREGNANCY.  285 

stood ;  it  is  believed  that  the  liver  and  the  thyroid  and  other 
glands  play  an  important  part  in  this  connection.  In  normal  cases 
the  destruction  and  elimination  of  poisons  is  carried  out  so  that 
health  is  in  no  way  disturbed.  In  many  cases  these  processes  are 
imperfect  as  a  result  of  defective  activity  of  the  protective  organs, 
excessive  accumulation  of  poisons,  or  of  a  combination  of  these. 
Many  factors  contribute  to  these  abnormalities — /.  c,  overeating, 
imperfect  digestion,  lack  of  exercise,  inattention  to  the  condition 
of  the  skin,  etc.,  being  frequently  noted.  Pinard  has  drawn  atten- 
tion to  the  influence  of  corset  constriction  in  impairing  the 
activity  of  the  liver,  whose  function  he  considers  of  prime  im- 
portance in  destroying  the  toxins  circulating  during  pregnancy. 
The  altered  abdominal  relationships  brought  about  by  the  increased 
size  of  the  uterus  may  also  interfere  directly  with  the  activity  of 
organs  through  increased  pressure  as  well  as  through  alterations 
in  the  circulation  of  blood  in  them.  In  some  cases  the  protective 
organs  act  inefficiently  because  they  are  congenitally  imperfect  or 
diseased. 

The  results  of  toxemia  or  autointoxication  vary  greatly.  Many 
of  the  so-called  "  minor  disturbances  "  in  early  pregnancy  are  sup- 
posed to  develop  because  the  protective  mechanism  does  not 
ordinarily  rapidly  accommodate  itself  to  the  necessity  for  destroying 
increased  toxic  material  in  the  system.  Various  disturbances  may 
be  noted,  notably  those  in  connection  with  the  nervous  system. 
The  alterations  in  the  skin  so  frequently  noted  are  believed  to  be 
thus  brought  about.  The  liver  is  frequently  affected  ;  sometimes 
it  may  be  markedly  degenerated — i.  e.,  in  acute  yellow  atrophy 
and  eclampsia.  The  kidneys  may  also  be  altered,  many  variations 
being  found  as  regards  the  changes  in  the  glandular  tissue  and  in 
the  excretion  of  waste  products. 

Diagnosis. — The  diagnosis  of  toxemia  in  pregnancy  is  to  be 
established,  in  accordance  with  the  views  above  expressed,  by 
studying  the  symptomatology  of  the  patient  and  by  noting  changes 
in  the  various  systems.  These  need  not  be  given  here,  because 
they  are  detailed  in  the  following  pages. 

Treatment. — Prophylactic  measures,  mainly  hygienic  and 
dietetic,  such  as  have  been  described  under  the  Hygiene  and 
Management  of  Pregnancy,  are  of  prime  importance  in  preventing 
the  development  of  toxemia.  When  a  toxic  condition  actually 
exists,  measures,  such  as  are  described  in  the  chapter  dealing  with 
Eclampsia,  should  be  adopted. 

In  dealing  with  the  so-called  "  minor  disturbances  "  of  preg- 
nancy the  physician  must  not  be  satisfied  with  seeking  for  a 
nostrum  that  may  give  relief  He  should  make  a  careful  study 
of  the  patient's  system  and,  remembering  the  toxic  theory  of  the 
disorders,  strive  to  carry  out  such  measures  as  are  calculated  to 
reduce  toxicity  to  a  minimum. 


286  AFFECTIONS    OF   THE   NERVOUS  SYSTEM. 

CHAPTER    II. 

AFFECTIONS  OF  THE  NERVOUS  SYSTEM. 

Sensory  disturbances  are  frequent.  Various  forms  of  neuralgia 
are  found — /.  c,  toothache.  The  breasts  are  sometimes  very  sensi- 
tive. Headaches  are  troublesome  to  some.  Abdominal  and 
pelvic  pains  may  be  present  as  the  result  of  old  inflammatory 
troubles  or  independently  of  them.  Sometimes  there  is  much 
distress  in  the  region  of  the  coccyx.  (Many  abdominal  and  pelvic 
disturbances  are  alimentary  in  origin  or  are  due  to  altered  pressure 
relationships.)  In  some  cases  there  are  symptoms  related  to  the 
sense  organs — /.  c,  ringing  in  the  ears,  altered  taste  and  smell, 
and  disturbed  vision.  These  and  various  other  nervous  alterations 
are  often  found  in  women  whose  health  is  deteriorated  and  in  those 
who  are  neurotic.  It  is,  however,  very  important  to  note  that 
many  of  these  disturbances  may  be  due  to  serious  disorders,  and 
that  they  should  never  be  treated  lighth^  unless  a  careful  and 
systematic  examination  of  the  woman  be  made. 

At  the  present  time  the  view  gains  ground  that  they  are  in 
large  measure  due  to  the  influence  of  toxins  that  circulate  in  the 
blood,  acting  as  direct  irritants  as  well  as  making  the  nervous 
centers  more  sensitive  to  all  reflex  stimuli.  Great  variations  are 
found  in  the  extent  to  which  they  are  affected.  Various  minor 
hysteric  manifestations  frequenth^  occur ;  extreme  outbreaks  are 
rare.  Insomnia  is  not  uncommon  ;  it  may  be  due  to  overworry, 
excessive  excitement  or  fatigue,  overuse  of  tea,  coffee,  and  other 
stimulants.  Sometimes  it  is  a  precursor  of  insanity ;  sometimes 
it  is  associated  with  an  organic  disease.  It  is  most  frequent  in 
neurotic  women. 

Mental  Affections. — In  describing  the  signs  and  symptoms 
of  pregnancy  various  common  minor  psychical  disturbances  were 
noted.  (Seep.  115.)  In  some  cases  these  maybe  marked  and 
may  persist  throughout  pregnancy,  disappearing  after  labor  ; 
occasional!}'  they  may  be  followed  by  insanity  in  labor  or,  more 
frequently,  in  the  puerperium.  An  outbreak  of  insanity  in  preg- 
nancy is  rare  in  an  adult  woman.  Clouston  states  that  after  the 
age  of  twenty-five  there  is  no  period  in  a  woman's  life  when  she  is 
less  liable  to  an  attack  than  during  gestation.  It  is  more  frequent 
in  primiparae  than  in  multiparse,  especially  in  cases  of  illegitimacy. 
An  important  predisposing  condition  is  a  hereditar}^  tendency  to 
insanity.  It  rarely  develops  before  the  third  month  ;  generally  not 
until  after  the  sixth  month.  The  onset  of  an  attack  is  generally 
gradual  and  marked  by  apathy.  There  may  be  marked  sluggish- 
ness and  stupor.     There  may  be  a  perversion  of  affection  toward 


PARALYSIS  AND   PARESIS— CHOREA    GRAVIDARUM.       287 

husband,  children,  or  other  near  relatives.  Sometimes  there  is 
marked  fear  of  an  impending  calamity.  The  condition  may  rapidly 
get  worse  and  a  state  of  dementia  follow.  Occasionally  the  in- 
sanity may  be  of  a  maniacal  type.  There  may  be  marked  hallu- 
cinations and  delusions  ;  sometimes  there  is  a  suicidal  tendency. 
Death  may  sometimes  follow  an  acute  attack  of  mania.  Recovery 
may  occasionally  take  place  before  labor.  More  frequently  it 
lasts  until  after  labor,  when  improvement  or  exaggeration  may 
be  noted. 

Treatment. — Insane  pregnant  women  should  be  treated  like 
those  who  are  not  insane.  They  should  not  be  taken  to  asylums 
unless  it  is  impossible  to  attend  to  them  in  a  quiet  private  house. 
Premature  delivery  is  not  indicated. 

Paralysis  and  Paresis. — These  may  be  mere  manifestations 
of  an  hysteric  condition  or  they  may  be  due  to  serious  organic 
disturbances.  The  lower  limbs  are  occasionally  affected  as  the 
result  of  the  pressure  exerted  by  the  uterus.  In  cases  of  paralysis 
due  to  brain  and  spinal-cord  lesions,  pregnancy  is  not  usually  in- 
terfered with  if  the  woman  lives.  When  the  lesion  is  higher  than 
the  lower  lumbar  region,  labor  may  go  on  satisfactorily  even 
though  the  abdominal  muscles  may  be  paralyzed. 

Kpilepsy. — When  this  disease  occurs  in  pregnancy  there  is 
usually  a  history  of  an  attack  at  a  previous  period  in  the  woman's 
life.  Pregnancy  occasionally  may  modify  the  epileptic  state,  dimin- 
ishing the  violence  and  number  of  the  convulsions  or  even  stop- 
ping them,  reappearance  being  noted  during  the  puerperium  or 
nursing-period  ;  but  in  most  instances  there  is  no  such  alteration. 
Sometimes  a  cessation  of  the  attacks  may  follow  labor  for  a  time. 
Epilepsy  does  not  seem  to  influence  the  course  of  pregnancy, 
though  injury  produced  during  a  convulsion  might  induce  prema- 
ture emptying  of  the  uterus.  Cases  should,  therefore,  be  watched 
with  special  care.  The  convulsions  of  epilepsy  must  be  diagnosed 
from  those  associated  with  hysteria,  uremia,  chorea,  eclampsia,  and 
apoplexy. 

Chorea  Gravidarum. — After  childhood  chorea  rarely  occurs 
save  in  pregnant  women,  and  it  does  not  frequently  affect  them. 
In  more  than  half  of  the  cases  the  women  are  primiparas.  They 
are  usually  neurotic  or  have  a  family  history  of  neuroses,  some- 
times of  insanity.  In  a  considerable  proportion  there  is  a  personal 
or  family  history  of  rheumatic  affections.  Occasionally  the  attack 
may  follow  fright,  shock,  or  marked  emotional  excitement.  There 
is  no  particular  association  with  illegitimacy.  In  about  50  per 
cent,  of  cases  the  manifestations  develop  during  the  first  three 
months  ;  in  nearly  all  the  remainder  during  the  next  three 
months  ;  in  only  a  few  instances  does  the  chorea  begin  during 
the  last  three  months.  Sometimes  the  disease  recurs  in  successive 
pregnancies.     When  gestation  occurs  in  women  already  suffering 


288  AFFECTIONS    OF   THE   AELRVOUS   SYSTEM. 

from  chorea  the  disease  may  rarely  be  checked.  Usually  it  con- 
tinues during  part  or  all  of  the  gestation,  and  may,  indeed,  last 
after  labor.  Frequently  the  disease  is  intensified.  When  mild 
the  movements  may  only  be  unilateral ;  in  severe  cases  they  are 
bilateral,  and  ma\'  continue  during  sleep  or  induced  narcosis. 
They  are  often  increased  as  the  result  of  fetal  movements  or  of  a 
physical  examination. 

Chorea  may  lead  to  marked  deterioration  of  health,  sleepless- 
ness, loss  of  flesh,  pareses,  and  to  various  mental  disturbances. 
In  severe  cases  premature  expulsion  of  the  ovum  may  be  caused. 
Recovery  from  the  disease  is  rare  until  pregnancy  has  terminated. 
The  mortality  of  the  disease  is  much  higher  in  pregnant  women 
than  in  children.  Buist  has  shown,  however,  that  in  a  consider- 
able number  of  cases  the  mortality  has  been  due  to  associated 
conditions — /.  c,  eclampsia,  sepsis,  etc.  The  fetus  may  die  in  ittcro, 
or  it  may  reach  term  and  be  born  weakly  or  well  developed.  In 
some  cases  it  ma)'  develop  chorea  in  early  childhood.  The  dis- 
ease must  be  chiefly  distinguished  from  hysteria.  Marie,  Gilles 
de  la  Tourette,  and  others  hold  that  true  chorea  is  rare,  and  that 
it  is  mistaken  for  hysteria  and  for  maladies  dcs  tics.  Sometimes 
chorea  and  hysteria  may  occur  together. 

Treatment. — The  general  and  medical  treatment  of  the  dis- 
ease is  the  same  as  in  the  non-pregnant  state.  Mild  cases  may 
be  improved  or  cured  and  carried  satisfactorily  to  term.  In 
severe  attacks  anesthesia  may  be  necessary  to  control  the  move- 
ments. When  the  movements  are  violent,  sleeplessness  is  marked 
and  health  deteriorates  ;  the  uterus  should  be  artificially  emptied. 

Tetanus. — Pregnane}^  seems  to  produce  a  condition  particu- 
larly favorable  to  the  growth  of  the  specific  organism  of  tetanus. 
In  the  tropics,  where  the  state  of  the  soil  favors  the  prevalence  of 
this  germ,  the  disease  is  not  infrequent  in  pregnant  women.  It  is 
more  common  in  multiparae,  especially  where  the  surroundings 
are  damp  and  dirt>\  The  attacks  generally  begin  in  the  early 
months  ;  the  maternal  mortality  is  high,  and  abortion  is  apt  to 
occur. 

Tetany. — Tonic  spasms  varying  in  degree  may  occasionally 
affect  the  pregnant  woman  ;  they  may  be  widespread  or  localized. 
In  mild  cases  they  usually  occur  only  in  the  upper  and  lower 
limbs.  They  are  usually  short  in  duration  and  intermittent,  and 
may  be  preceded  or  followed  by  numbness  or  tingling.  Com- 
pression of  the  main  nerves  or  vessels  in  the  affected  parts  may 
renew  the  spasms.  The  application  of  cold  usually  checks  them. 
In  marked  cases  the  face  and  trunk  muscles  may  be  affected. 
There  is  usually  a  slight  rise  of  temperature,  quickened  pulse,  and 
disordered  digestion.  Rarely  death  may  occur  from  interference 
with  respiration.  Consciousness  is  never  lost.  The  condition 
must  be  diagnosed  from  tetanus,  epilepsy,  and  hysteria. 


HEMOPOIETIC  AND    CIRCULATORY  SYSTEMS.  289 

Treatment. — The  general  health  should  be  improved  and  all 
weakening  or  irritating  conditions  removed.  Quietness  and  sleep 
are  necessary.  Bromids  and  other  sedatives  are  often  advisable. 
In  severe  cases  it  is  necessary  to  empty  the  uterus. 

Shock. — The  effect  of  shock  on  the  pregnant  woman  varies 
greatly.  She  may  recover  quickly,  no  apparent  disturbances  fol- 
lowing. Various  nervous  and  mental  affections  may  result.  Fre- 
quently premature  expulsion  of  the  ovum  is  caused.  In  general, 
therefore,  it  may  be  said  that  no  unnecessary  surgical  procedure 
should  be  carried  out  during  pregnancy,  even  though  recovery 
may  take  place  after  such  operations  as  ovariotomy,  herniotomy, 
myomectomy,  etc.,  without  interruption  of  the  gestation.  Gen- 
eral anesthesia  should  always  be  used.  Local  anesthesia  is  con- 
traindicated  ;  for  while  it  may  be  satisfactory  so  far  as  the  opera- 
tion is  concerned,  it  cannot  prevent  psychical  disturbance  or  shock, 
which  may  be  sufficient  to  cause  abortion. 

Hysteria  is  rarely  influenced  favorably  by  pregnancy.  Its 
manifestations  may  sometimes  disappear,  but  often  they  are  ag- 
gravated. It  does  not  tend  to  interfere  with  the  course  of  gesta- 
tion. 

Catalepsy  is  a  very  rare  complication  of  pregnancy.  The 
infant  may  be  affected  at  birth. 


CHAPTER    III 


AFFECTIONS  OF  THE  HEMOPOIETIC  AND  CIRCULA- 
TORY SYSTEMS. 

Changes  in  the  Spleen. — Excessive  enlargement  of  the 
spleen  sometimes  takes  place  in  pregnancy.  It  may  cause  a 
swelHng  in  the  abdomen  and  produce  aching  or  pain  in  the  side. 
Rarely  rupture  has  occurred  during  pregnancy,  usually  as  the 
result  of  a  strain  or  fall ;  this  has  also  taken  place  during  and 
after  labor. 

Changes  in  the  Thyroid. — Exophthalmic  goiter  sometimes 
begins  in  pregnancy,  the  disease  being  usually  of  an  aggravated 
type.  It  may  cause  fetal  death  and  premature  emptying  of  the 
uterus  from  circulatory  disturbances.  After  pregnancy  the  con- 
dition generally  improves.  In  extreme  cases,  if  symptoms  are 
becoming  serious,  pregnancy  should  be  ended.  Cystic  disease  of 
the  thyroid  or  bronchocele  may  begin  in  pregnancy,  especially  in 
districts  where  the  disease  is  endemic.  Sometimes  a  rapid  growth 
may  endanger  respiration.  In  these  cases  the  uterus  should  be 
emptied.      Altered   activity   of  the   thyroid   and   parathyroids  is 

19 


290  HEMOPOIETIC  AND    CIRCULATORY  SYSTEMS. 

believed  by  many  to  explain  some  of  the  pathologic  changes 
complicating  pregnancy — /.  e.,  eclampsia  and  vomiting. 

Changes  in  the  Blood. — The  normal  changes  have  already 
been  described.  (See  p.  107.)  True  anemia  or  chlorosis  may 
begin  in  pregnancy,  but  generally  it  is  an  aggravation  of  a  condi- 
tion that  existed  before  gestation.  The  disease  may  be  much 
intensified.  Sometimes  pernicious  anemia  may  develop ;  if  it  has 
existed  before  pregnancy  it  becomes  worse  afterward.  Of  25 
cases  of  the  latter  affection  reported  by  Graefe  only  i  was  cured  ; 
2  became  somewhat  better  after  labor ;  most  died  within  ten 
months  of  the  onset.  H.  W.  Freund  states  that  most  deaths 
occur  after  labor,  generally  within  five  months.  Anemia  may 
cause  abortion  by  death  of  the  fetus  from  imperfect  nutrition, 
deficient  oxygenation,  and  placental  hemorrhages.  The  treatment 
of  anemia  is  the  same  as  in  the  non-pregnant  state.  When  the 
condition  is  marked  and  does  not  improve  or  is  pernicious  the 
uterus  should  be  prematurely  emptied. 

Hemophilia  is  rare ;  it  may  develop  in  pregnancy  and  is  a 
dangerous  complication.  If  hemorrhage  occurs  during  pregnancy 
or  labor  the  result  may  be  fatal.  Purpura  hsemorrhagica  may 
also  be  very  serious  during  pregnancy.  Hemorrhages  in  the 
placenta  may  kill  the  fetus  and  its  expulsion  may  follow.  The 
fetus  itself  is  usually  free  from  purpura.  In  these  cases  calcium 
chlorid  should  be  administered  internally.  If  marked  bleeding 
occurs  a  sterile  2  per  cent,  normal  saline  solution  of  gelatin  may 
be  tried  subcutaneously.  Adrenalin  chlorid  may  also  be  adminis- 
tered. 

Changes  in  the  Arteries. — Sometimes  fatty  changes  are 
found  in  the  intima  of  the  aorta  or  other  large  vessels  ;  more 
rarely  in  the  media.  These  may  be  succeeded  by  sclerosis  and 
calcareous  deposition.  Dissecting  aneuiysm  may  thus  be  caused. 
Telangiectatic  tumors  may  form  during  pregnancy.  Aneurysm 
is  unfavorably  affected  by  pregnancy  because  of  the  cardiac  hyper- 
trophy, increased  quantity  of  blood,  and  interference  with  the  cir- 
culation ;  the  artery-wall  is  likely  to  degenerate  still  more.  A  case 
should  be  treated  on  the  lines  laid  down  for  the  management  of 
pregnancy  complicated  with  heart  disease.  Rupture  may  occur 
during  or  after  labor. 

Changes  in  the  Veins. — As  a  result  of  the  increased  diffi- 
culties encountered  by  the  pelvic  circulation  in  pregnancy,  owing 
to  the  growth  of  the  uterus,  its  relationship  to  the  pelvic  brim,  the 
increase  of  intra-abdominal  pressure,  and  the  altered  state  of  the 
blood,  venous  engorgement  in  the  pelvis  is  common  in  pregnancy, 
varicosities  being  formed  in  different  parts — /.  c,  broad  ligaments, 
external  genitals,  bladder,  rectum,  lower  limbs,  and  abdominal 
walls.  The  saphena  veins  are  most  frequently  affected  ;  next,  the 
veins  on  the  inner  side  of  the  calf;  the  vulvar  veins  are  less  often 


EDEMA— CARDIAC  AFFECTIONS.  29 1 

varicose.  The  condition  is  more  common  in  multiparas  Chronic 
constipation  is  an  important  factor  in  its  production,  especially  in 
the  i-ectum.  Sometimes  edema  may  accompany  the  varicose  con- 
dition. Rupture  of  a  vein  may  occur,  forming  a  hematoma,  which 
occasionally  may  suppurate.  Thrombosis  and  phlebitis  may 
occur.  From  an  infected  vein  the  lymphatics  may  be  affected. 
As  the  result  of  scratching  the  skin  may  become  infected.  Hemor- 
rhoids may  lead  to  loss  of  blood  and  to  much  distress  ;  they  may 
become  inflamed,  ulcerated,  or  gangrenous. 

Treatment. — The  aHmentary  tract  should  be  well  regulated. 
The  patient  should  be  enjoined  to  lie  on  her  back,  the  hips  being 
higher  than  the  head,  an  hour  or  two  in  the  early  afternoon  every 
day.  It  may  be  necessary  to  keep  her  in  bed  for  a  considerable 
time  in  order  to  improve  the  varicose  condition.  Elastic  pressure 
over  the  vulva  is  sometimes  necessary.  Elastic  stockings  are 
valuable  when  the  lower  limbs  are  affected. 

When  there  is  phlebitis  or  thrombosis  absolute  rest  is  neces- 
sary, the  limb  being  wrapped  in  cotton  and  slightly  elevated.  If 
there  be  much  pain,  soothing  applications — /.  c,  lead  and  opium 
lotion,  may  be  used.  In  these  conditions  the  greatest  care  must 
be  taken  and  the  danger  of  embolism  remembered.  Scratching  of 
the  skin  over  affected  areas  must  be  prevented.  A  suppurating 
area  must  be  opened  early  and  treated  with  antiseptics.  Piles 
should  be  treated  as  much  as  possible  by  medical  means.  When 
they  continue  to  bleed  extensively  or  are  badly  ulcerated  or  gan- 
grenous it  may  be  necessary  to  employ  surgical  measures. 

Kdema  may  occur  in  different  parts  of  the  body  as  the  result 
of  the  various  causes  that  may  produce  the  condition  in  the  non- 
pregnant woman.  In  pregnancy  it  is  most  frequent  in  the  lower 
extremities  and  vulva ;  sometimes  in  the  lower  abdominal  region. 
It  is  sometimes  associated  with  varicose  veins.  It  is  found  in 
anemia,  in  heart,  kidney,  and  some  liver  diseases  ;  in  conditions 
where  there  is  abnormal  intra-abdominal  pressure — /.  e.,  hydram- 
nios,  twin  pregnancy,  tumor  with  pregnancy,  etc.  Edema  may 
sometimes  be  associated  with  gangrene. 

Treatment. — Attention  should  be  given  to  the  primary  cause. 
Increased  diuresis  and  diaphoresis  must  be  encouraged.  Regular 
daily  rest  or  even  continuous  rest  may  be  necessary.  In  cases  of 
extreme  swelling  it  is  advisable  to  allow  the  fluid  to  escape  by 
puncture  under  careful  aseptic  precautions. 

Cardiac  Affections. — The  normal  changes  in  the  heart  during 
pregnancy  have  already  been  noted.  (See  p.  108.)  The  organ 
may  become  weakened  in  action  and  somewhat  dilated  in  various 
states  of  pregnancy — /.  e.,  advanced  hydramnios  or  twin  gestation, 
abdominal  swellings  coexistent  with  pregnancy,  and  some  lung 
affections.  Palpitation,  breathlessness,  irregular  pulse,  cyanosis, 
etc.,  may  occur  as  a  result.     Sometimes  these  symptoms  may  be 


292  HEMOPOIETIC  AND    CIRCULATORY  SYSTEMS. 

caused  by  extreme  flatulence  in  advanced  gestation.  They  may 
also  appear  as  neuroses. 

True  valvular  disease  rarely  begins  in  pregnancy.  When  it  does 
it  is  probably  mainly  due  to  one  of  the  influences  that  lead  to  its 
production  in  the  non-pregnant  state — /.  c,  rheumatism.  Certain 
authors,  however,  think  that  a  true  pregnancy  endocarditis  may 
arise.  They  point  out  the  conditions  that  may  favor  valvular 
changes — i.  c,  hypertroph}',  dilatation,  altered  blood-pressure,  and 
increase  of  iibrin  elements  in  the  blood.  Ollivier  has  described  3 
cases  in  which  endocarditis  seemed  to  develop  as  a  result  of  preg- 
nancy influences.  He  thinks  that  the  mitral  valve  is  most  likely 
to  be  affected.  The  question  is  not  easy  to  settle,  though  it  must 
be  admitted  that  the  circulatoi-}'  conditions  of  pregnancy  would 
undoubtedly  favor  the  development  of  vahular  disease  if  a  rheu- 
matic or  septic  influence  were  present. 

Acute  endocarditis  is  very  rarely  found  in  pregnancy,  and  must 
be  regarded  as  a  more  serious  disease  than  it  is  in  the  non- 
pregnant. The  great  majority  of  cases  are  those  of  chronic  valvular 
disease  of  the  left  side  of  the  heart  that  existed  before  the  preg- 
nancy began.  Right-sided  disease  is  so  rare  that  it  need  not  be 
especially  considered.  The  gravest  cases  are  those  in  which 
pregnane)'  occurs  before  compensation  has  been  well  established 
after  recent  mitral  or  aortic  disease,  especially  after  the  latter.  Of 
the  cases  in  which  the  endocarditis  is  not  recent,  compensation 
having  been  well  established,  mitral  stenosis  is  the  most  serious 
form  of  heart  lesion.  Of  the  two  valves,  the  mitral  is  more  fre- 
quently affected  than  the  aortic ;  sometimes  both  are  diseased. 

The  effects  of  pregnancy  on  a  woman  who  has  a  valvular  lesion 
vary  greath'.  These  depend  upon  a  variety  of  factors — /.  c,  the 
situation  and  extent  of  the  disease,  the  degree  of  compensation 
existing  at  the  beginning  of  pregnancy,  the  general  health  of  the 
patient,  her  habits,  occupations,  etc.  The  nutrition  of  the  cardiac 
muscles  may  be  affected  by  an  abnormally  pooi'  state  of  the  blood. 
The  resulting  weakness  would  tend  to  favor  early  or  rapid  failure 
in  compensation.  There  is  always  a  danger,  especially  when  the 
disease  is  recent,  that  fresh  fibrin  vegetations  may  form  on  the 
valve  owing  to  the  increased  hyperinosemia  of  the  blood  of  the 
pregnant  woman.  In  some  cases  also,  apart  from  mechanical 
stretching  that  may  gradually  affect  the  valve,  there  may  be 
recrudescence  of  the  original  disease,  which  may  lead  to  further 
destruction  of  the  valve.  The  main  element  of  danger  common 
to  all  cases  is  undoubtedly  the  increased  work  thrown  on  the 
heart,  due  to  the  greater  quantity  of  circulating  blood.  This 
factor  is  most  serious  in  the  advanced  months  of  gestation,  when 
the  uterus  reaches  a  large  size. 

Another  influence  that  plays  a  role  is  distention  of  the  abdo- 
men, especially  if  this  be   abnormal   from  excessive   size  of  the 


CARDIAC  AFFECTIONS.  293 

uterus,  as  in  hydramnios,  twins,  or  single  large  child  ;  in  disordered 
alimentary  states  where  flatulence  and  constipation  occur.  Of  great 
importance  are  disturbed  metabolism  and  imperfect  elimination, 
whereby  toxic  matters  circulate  and  directly  poison  the  cardiac 
muscle.  Indeed,  the  various  factors  introduced  by  pregnancy  are 
so  serious  that  effects  may  be  brought  about  that  in  the  non- 
pregnant state  might  not  be  met  with  until  after  a  period  of  years. 
The  woman  with  heart  disease,  ccstcris  paribus,  has  a  shorter  life 
expectation  if  she  exercises  the  function  of  child-bearing,  and  her 
dangers  increase  with  succeeding  pregnancies.  In  some  cases, 
owing  to  the  perfect  response  of  the  heart  to  additional  strain 
thrown  upon  it,  the  woman  may  pass  through  pregnancy  with  no 
more  discomfort  than  may  be  found  in  normal  cases.  When, 
however,  cardiac  compensation  is  not  sufficient,  one  or  more  of 
the  well-known  signs  and  symptoms — i.  c,  breathlessness,  cough, 
dyspnea,  edema,  etc.,  make  their  appearance.  In  aortic  disease 
disturbances  are  less  common  and  usually  less  severe  than  in 
mitral  disease,  and  they  appear  in  most  cases  during  the  late  months 
of  gestation.  The  symptoms  are  mainly  palpitation  and  dyspnea. 
In  some  cases  premature  emptying  of  the  uterus  may  be  caused. 
It  is  in  mitral  disease,  especially  where  stenosis  exists,  that  the 
most  marked  symptoms  occur,  and  though  they  usually  supervene 
after  midterm,  they  may  often  develop  earlier.  The  increased 
risk  to  the  woman  in  mitral  disease,  especially  in  stenosis,  is  pul- 
monary congestion,  and  dilatation  and  weakness  of  the  right  side  of 
the  heart. 

The  health  of  the  fetus  tends  to  be  impaired,  both  from  the 
imperfectly  oxygenated  condition  of  the  maternal  blood  as  well  as 
from  the  destruction  of  portions  of  the  placenta  by  hemorrhages 
into  it  from  the  maternal  vessels.  Expulsion  of  the  uterine  con- 
tents may  thus  be  brought  about.  In  pregnancy  death  may  result 
sometimes  from  heart  failure  without  the  occurrence  of  premature 
emptying  of  the  uterus,  but  in  most  cases  the  fatality  is  associated 
with  this  event  or  follows  it.  It  has  been  reported  in  connection 
with  an  abortion  in  early  pregnancy,  though  this  is  rare.  Very 
few  women  go  to  full  time  without  the  appearance  of  some  ab- 
normal signs  and  symptoms.  These  vary  considerably  in  different 
cases.  Most  frequent  are  dyspnea,  palpitation,  and  edema,  and 
these  may  be  slight  or  marked.  When  pulmonary  congestion  and 
dilatation  of  the  right  heart  increase  the  outlook  is  serious. 
Ascites,  albuminuria,  hemorrhages,  and  embolism  are  also  very 
grave  signs.  The  majority  of  cases  which  go  to  term  become 
worse  during  the  last  weeks,  the  symptoms  being  more  pronounced 
if  there  be  alimentary  disorders  cau.sing  flatulence,  and  thereby 
increased  pressure  on  the  heart  through  the  diaphragm.  In  addi- 
tion, patients  often  become  despondent  and  nervous,  lose  their 
appetite,  and  suffer  from  sleeplessness  at  this  time. 


294  HEMOPOIETIC  AND    CIRCULATORY  SYSTEMS. 

Treatment. — As  regards  the  influence  of  cardiac  disease  in 
deciding-  the  question  of  marriage  different  views  are  held.  Very 
common  is  the  opinion  that  no  woman  with  organic  heart  disease 
should  marry  if  her  well-being  alone  be  taken  into  consideration. 
Some  authorities  would  insist  upon  this  restriction  only  in  special 
cases — /.  c,  mitral  stenosis,  when  the  woman's  general  health  is 
not  good,  or  when  some  other  lesion  exists.  When  pregnancy 
takes  place  the  woman  should  be  carefully  looked  after  from  the 
beginning,  her  dail}-  routine  being  regular  and  well  ordered.  She 
must  be  guarded  from  strain,  worr)^,  anxiety,  and  sudden  shock. 
The  diet  should  be  very  nourishing,  easily  digested,  and  the  bowels 
should  be  carefully  regulated.  The  woman  should  stay  out-of- 
doors  as  much  as  possible  in  fine  weather,  avoiding  chills  and 
dampness.  She  may  take  easy  walks  and  carriage  drives,  but  in 
the  late  months  must  be  kept  more  at  rest.  Massage  of  the  limbs 
is  frequent!}'  beneficial. 

As  to  medicinal  treatment,  none  is  required  in  the  few  cases 
which  have  no  abnormal  symptoms  or  signs  during  pregnancy. 
In  most  cases,  however,  tonics  are  needed — i.  c,  iron,  arsenic,  and 
strychnin.  Strophanthus  and  digitalis  and  nitro-glycerin  are  of 
the  greatest  value  in  strengthening  the  heart  muscle,  and  are  in- 
dicated when  there  are  signs  of  heart  failure — /.  c,  breathlessness, 
dyspnea,  cough,  edema,  increasing  irregularity  and  weakness  of 
pulse,  etc.  When  digitalis  is  used  a  nitrite  should  be  given  at 
the  same  time  in  order  to  counteract  the  effect  of  the  former  in 
contracting  the  arterioles  and  so  raising  arterial  resistance. 

If  abortion  or  premature  labor  threatens,  what  is  to  be  done  ? 
It  is  difficult  to  speak  decidedly  with  reference  to  this  question. 
Some  authorities  ad\'ise  encouraging  the  emptying  of  the  uterus ; 
others  are  guided  by  the  condition  of  the  mother.  If  she  be  in  a 
good  state  an  effort  should  be  made  to  carry  on  the  gestation. 
This  is  effected  by  enjoining  absolute  rest  in  bed,  together  with 
morphin  administration.  Sometimes  it  is  advisable  to  bleed  the 
patient  once  or  twice.  If  the  patient  shows  evidence  of  heart 
failure  in  connection  with  the  signs  of  premature  expulsion,  many 
authorities  believe  that  the  pregnancy  should  be  terminated.  When 
symptoms  of  cardiac  weakness  develop  in  pregnancy,  though  pre- 
mature expulsion  of  the  ovum  be  not  threatened,  should  the  uterus 
always  be  emptied  ?  Here  again  different  views  are  expressed. 
Some  hold  that  any  symptoms  whatever  justify  the  termination  of 
pregnancy  ;  this  is  too  advanced  a  position.  Many  cases  ma}-  be 
carried  to  full  term  by  careful  therapeutic  measures,  even  though 
they  may  be  troubled  with  palpitation,  dyspnea,  or  edema  of  the 
limbs. 

When  more  severe  signs  arise — /.  r.,  increasing  dilatation  and 
irregularity  of  the  heart,  pulmonary  edema  and  congestion,  ascites, 
albuminuria,  etc.,  the  uterus  should  be  emptied   in  the  great  ma- 


AFFECTIONS    OF   THE   RESPIRATORY  SYSTEM.  295 

jority  of  cases  unless  the  husband  and  wife  refuse  their  consent. 
Occasionally  the  failure  in  heart  compensation  may  be  checked 
even  where  one  or  two  of  these  grave  conditions  are  present ;  but 
if  improvement  is  not  noted  early  too  much  time  must  not  be 
wasted  before  the  uterus  is  emptied.  In  all  cases  in  which  rapid 
benefit  is  desired,  venesection  stands  prominent  as  a  therapeutic 
measure.  In  considering  the  question  of  terminating  pregnancy, 
it  must  always  be  remembered  that  this  procedure  may  be  as 
dangerous  as  a  full-time  labor,  especially  when  the  signs  of  cardiac 
failure  are  marked.  The  operation  must  be  carried  out  with 
special  precautions,  which  have  for  their  object  the  avoidance  of 
all  straining  on  the  part  of  the  woman  and  of  sudden  rise  in  the 
blood-pressure.  These  will  be  described  in  connection  with  the 
Pathology  of  Labor. 


CHAPTER    IV. 
AFFECTIONS  OF  THE  RESPIRATORY  SYSTEM. 

Cougfh. — Pregnant  women  are  frequently  troubled  with  a 
cough  that  is  not  due  to  recognizable  changes  in  the  respiratory 
tract.  In  such  cases  it  is  usually  regarded  as  a  neurosis  of  reflex 
origin.  Apart  from  this  variety,  it  may  be  due  to  any  of  the 
causes  that  exist  in  the  non-pregnant  state.  Excessiv^e  or  pro- 
tracted coughing  may  cause  abdominal  and  pelvic  pains  and  may 
bring  about  abortion. 

Sneering". — Occasionally  sneezing  is  a  complication  of  preg- 
nancy, especially  in  the  early  months.  It  may  lead  to  nasal 
hemorrhage  ;  sometimes  abortion  may  be  caused.  The  application 
of  cocain  has  proved  a  valuable  remedy. 

Dyspnea. — Occasionally  dyspnea  affects  pregnant  women, 
especially  in  the  early  months,  being  of  reflex  nervous  origin.  In 
advanced  gestation  it  is  frequently  present,  being  due  to  the  in- 
creasing abdominal  distention.  It  is  most  marked  when  the  uterus 
is  abnormally  large,  when  there  is  extreme  flatulence,  or  when 
there  is  a  new  growth  in  the  abdomen.  It  may  also  be  caused  by 
various  diseases  affecting  the  respiratory  and  circulatory  systems. 

Bronchitis. — This  disease  may  cause  much  distress  if  it  be 
extensive,  especially  in  the  later  months.  The  woman  may  be- 
come weakened  from  the  troublesome  coughing,  which  may  cause 
abortion. 

I/Obar  Pneumonia. — This  is  a  serious  complication  of  preg- 
nancy, especially  when  both  lungs  are  affected.  The  circulation 
is  more  embarrassed  than  in  the  non-pregnant  state.     Owing  to 


296  AFFECTIONS    OF   THE   RESPIRATORY  SYSTEM. 

imperfect  oxygenation  the  nutrition  of  the  cardiac  muscle  is 
affected,  and  there  is,  consequently,  a  tendency  to  heart  failure. 
The  high  temperature  and  imperfectly  oxygenated  blood  may 
destroy  the  ovum  and  so  lead  to  its  premature  expulsion.  The 
cough  may  also  be  a  factor  in  bringing  this  about.  Wallich  states 
that  the  uterus  is  emptied  in  one-third  of  the  cases  in  which  the 
pneumonia  occurs  before  the  sixth  month,  and  in  two-thirds  after 
this  period.  Sometimes  premature  labor  takes  place,  the  child 
being  born  ahve ;  occasionally  it  may  show  signs  of  pneumonia. 
The  greatest  risk  to  the  mother  is  in  the  puerperium.  Wallich 
estimates  the  maternal  mortalit)'  at  more  than  50  per  cent.,  and 
the  fetal  at  80  per  cent. 

Treatment. — The  woman  must  be  treated  by  the  ordinary 
well-recognized  methods.  When  there  is  marked  cyanosis  or 
asphyxia  oxygen  inhalation  is  indicated ;  wet-cupping  and  vene- 
section are  also  of  great  value.  Continued  cardiac  stimulation  is 
imperative.  The  uterus  should  not  be  emptied,  but,  rather,  every 
effort  should  be  made  to  pre\ent  this  from  taking  place,  in  order 
to  avoid  increased  risk  to  the  woman. 

Asthma  occurs  in  some  women  only  in  pregnancy  or  labor, 
disappearing  afterward.  W'hen  pregnancy  takes  place  in  women 
who  are  subject  to  asthma  the  attacks  are  usually  aggravated. 

Pleurisy  appearing  as  an  acute  attack  may  not  have  any 
special  effect  on  pregnancy.  If,  however,  an  extensive  effusion 
forms,  cardiac  embarrassment  may  be  caused.  In  cases  of  old- 
standing  extensive  pleuritic  adhesions  the  heart  may  be  affected, 
so  that  it  may  not  be  equal  to  the  increased  work  thrown  upon  it 
as  a  result  of  pregnancy. 

Hmphysema,  if  extensive,  may  be  a  serious  condition  if  it 
has  caused  cardiac  changes.  Premature  expulsion  of  the  ovum 
is  apt  to  occur. 

Hemoptysis  is  almost  always  due  to  phthisis  or  heart  disease. 

Phthisis  Pulmonalis. — Advanced  phthisis  tends  to  prevent 
conception,  but  in  its  early  stages  the  disease  has  no  effect  in  this 
direction.  The  progress  of  pre-existent  phthisis  is  only  rarely 
retarded  by  pregnancy.  The  popular  belief  that  gestation  is  bene- 
ficial is  wrong,  and  probably  arises  from  the  observation  that  the 
woman  often  gains  fat.  In  most  cases  the  disease  develops  more 
rapidly  and  terminates  sooner  because  of  the  pregnancy.  In 
women  predisposed  to  the  disease,  gestation  may  determine  the 
beginning  of  an  attack  before  or  after  labor.  Sometimes  such 
women  may  have  one  or  more  children  before  the  disease  starts. 
Occasionally  a  woman  dies  from  rapid  progress  of  the  phthisis 
during  pregnancy.  When  it  is  advanced,  premature  emptying  of 
the  uterus  may  take  place.  When  a  diseased  woman  goes  through 
labor  she  is  usually  much  weakened  and  generally  has  little  milk. 
The  children  are  usually  feeble  and  are  predisposed  to  tuberculosis. 


AFFECTIONS   OF   THE    OSSEOUS  SYSTEM.  297 

Occasionally  they  are  tuberculous   at  birth,   dying    soon  after- 
ward. 

The  question  of  inducing  abortion  in  phthisic  women,  both  on 
account  of  the  mother  and  the  fetus,  is  one  the  physician  may  be 
asked  to  decide.     There  can  be  no  doubt  as  to  its  justifiability. 


CHAPTER   V. 

AFFECTIONS  OF  THE  OSSEOUS  SYSTEM. 

Tuberculosis  of  bones  tends  to  become  aggravated  in  preg- 
nancy. 

Osteomalacia. — This  disease,  which  causes  softening  and 
deformities  of  the  bones,  is  very  rare  in  America ;  it  is  chiefly 
found  in  Germany,  Italy,  Austria,  and  Switzerland.  In  some 
parts  it  seems  to  be  endemic.  It  affects  both  sexes,  but  is 
chiefly  found  in  women.  There  are  different  statements  as  to  the 
frequency  of  its  occurrence  in  pregnant  women.  Litzmann  says 
that  it  is  found  in  them  in  64.88  per  cent,  of  the  cases ;  Hennig, 
in  68.2  ;  Casati,  in  64.9  ;  Geepke,  in  94.8.  Durham  states  that  in 
131  cases  the  first  symptoms  appeared  in  91  at  or  soon  after 
childbirth.  The  pelvic  bones  are  first  and  most  seriously  affected 
in  women.  Ritchie  points  out  that  the  frequent  recurrence  of 
pregnancy  favors  the  production  of  the  disease.  He  states  that 
it  is  doubtful  if  prolonged  lactation  is  a  favoring  condition. 
Fehling  says  that  the  disease  is  limited  to  the  years  of  sexual 
activity. 

Symptoms. — The  onset  of  the  disease  is  obscure.  Pains  in 
the  sacrum,  in  the  other  pelvic  bones,  or  in  the  spinal  column  are 
usually  early  symptoms  ;  they  are  generally  constant,  though  they 
may  vary  in  degree,  being  increased  by  pressure  or  movements. 
Then  difficulty  in  walking,  or  in  flexing  the  thighs  on  the  ab- 
domen, is  noticed,  and  the  o-ait  becomes  awkward  and  waddlinsf. 
Then  the  bones  may  bend,  the  height  of  the  patient  diminishes, 
the  spine  may  become  twisted  and  the  thorax  deformed.  (Changes 
in  the  pelvis  are  described  in  the  chapter  on  Deformed  Pelves.) 

Frequently  there  is  early  increase  in  the  knee-jerk  and  ankle- 
clonus.  There  may  also  be  rhythmic  movements  like  those  in 
cerebrospinal  sclerosis.  Paresis  of  the  flexors  of  the  hip  and 
contracture  of  the  adductors  may  be  noted.  Pregnancy  causes 
the  disease  to  advance  rapidly,  and  the  patient  is  generally  com- 
pelled to  take  to  her  bed. 

There  are  variations  in  the  morbid  changes.  The  chief  feature 
is  the  absorption  of  bone ;  in  some  cases  only  the  earthy  salts  are 


298  AFFECTIONS   OF   THE   ALIMENTARY  TRACT. 

-removed.  With  the  absorptive  process,  regeneration  may  also  be 
in  progress.  In  the  late  stages  the  bones  may  easily  be  cut  with 
a  knife.  There  is  congestion  in  the  bone-vessels,  and  often  small 
hemorrhages,  but  there  is  no  evidence  of  inflammation. 

Fehling  has  pointed  out  the  tendency  to  marked  friability  in 
the  ovaries  and  to  the  frequent  occurrence  of  extreme  congestion 
in  the  uterine  adnexa. 

Etiology. — As  to  the  etiology  there  are  different  theories,  the 
most  plausible  being  that  of  Curatulo,  who  holds  that  the  ovaries 
introduce  into  the  blood  an  internal  secretion  that  promotes  oxida- 
tion of  the  phosphoric  organic  substances  necessary  to  form  the 
bony  salts. 

Treatment. — In  early  pregnancy  the  uterus  should  be  emptied 
and  the  ovaries  removed  ;  in  late  pregnancy  Csesarean  or  Porro- 
Caesarean  section  and  oophorectomy.  Removal  of  the  ovaries  is 
followed  in  many  cases  by  cure.  Sometimes  the  cure  is  only 
partial ;  occasionally  there  is  no  change.  Senator  treated  a  case 
by  administering  oophorin.  There  was  a  certain  degree  of  im- 
provement, the  patient  excreting  a  smaller  quantity  of  lime  salts, 
but  the  results  were  not  satisfactory. 


CHAPTER    VI. 

AFFECTIONS  OF  THE  ALIMENTARY  TRACT. 

Caries  of  the  Teeth. — The  teeth  are  apt  to  decay  in  preg- 
nancy, and  the  change  is  more  rapid  than  in  the  non-pregnant 
state.  Toothache  is  apt  to  be  troublesome  in  these  cases.  Severe 
or  extended  dental  work  should  not  be  carried  out  in  pregnancy ; 
temporary  fillings  only  should  be  made.  Toothache  is  sometimes 
present  when  no  caries  exists.  Assuma  points  out  that  the  cause 
of  caries  is  not  that  which  has  frequently  been  asserted — viz.,  ab- 
sorption of  mineral  matter  from  the  teeth.  He  shows  that  the 
disease  is  due  primarily  to  the  erosive  action  Of  acid  secretions, 
permitting  the  subsequent  growth  of  leptothrix.  The  buccal 
secretion,  normally  alkaline,  readily  ferments  and  becomes  acid  in 
pregnant  v/omen.  A  mouth  wash  of  sodium  bicarbonate  is  a 
valuable  prophylactic  measure  in  pregnancy. 

Ptyalism. — This  is  frequently  found,  though  varying  in  extent 
in  different  cases.  Sometimes  it  may  be  very  marked  and  may 
recur  in  succeeding  gestations.  It  may  sometimes  be  reflexly 
induced  by  pathologic  conditions  in  the  pelvis,  and  may  be  les- 
sened by  improving  these.  Thus,  the  replacement  of  a  retroverted 
uterus  may  lead  to  its  disappearance. 


GINGIVITIS— ACUTE    YELLOW  ATROPHY.  299 

Treatment  is  not  very  satisfactory.  Ptyalism  may  be  some- 
what checked  by  the  sucking  of  ice  or  by  astringent  washes  ; 
belladonna  may  be  necessary.  Galvanism  applied  to  the  salivary 
glands  is  sometimes  beneficial,  2  or  3  milliamperes  being  given 
five  or  ten  minutes  daily. 

Gingivitis. — Sometimes  this  affection  is  very  troublesome, 
the  gums  being  inflamed  or  even  ulcerated  and  bleeding  easily. 
It  may  be  associated  with  catarrhal  changes  in  the  stomach.  In 
treating  the  condition  strict  regulation  of  the  diet  is  advisable. 
Astringent  antiseptic  mouth  washes  should  be  used. 

Pica  or  Malacia. — The  craving  for  eating  various  articles 
has  already  been  described.  (See  p.  115.)  This  peculiarity  may 
or  may  not  be  associated  with  digestive  disorders. 

Pyrosis. — Heartburn  is  frequent,  especially  in  the  late  months 
of  gestation.  It  is  usually  associated  with  alimentary  disorders. 
It  is  often  worse  toward  evening,  in  some  cases  being  present  only 
at  that  time. 

Diarrhea. — This  disorder  is  generally  associated  with  other 
digestive  disturbances  and  may  alternate  with  constipation.  If  the 
condition  continues  the  woman  may  become  much  weakened  and 
abortion  may  result. 

Constipation. — This  disturbance  is  often  found,  and  is  aggra- 
vated by  indiscretions  of  diet  and  lethargic  habits.  It  may  lead  to 
loss  of  appetite  and  to  various  digestive  disorders.  Hemorrhoids 
are  frequent  and  prolapse  of  the  rectum  may  take  place.  Of  great 
importance  is  the  poisoning  of  the  system  as  the  result  of  absorp- 
tion of  toxic  matters  from  the  bowel. 

Hepatic  Toxemia. — Alterations  of  the  liver  function  are 
more  frequent  in  pregnancy  than  is  generally  known.  The  organ 
plays  a  very  important  role  in  destroying  various  circulating 
toxins.  When  it  is  unequal  to  the  demands  put  upon  it,  increased 
work  is  thrown  on  the  kidneys  and  other  organs.  Sainte-Blaise 
says  that  the  following  conditions  are  indicative  of  hepatotoxemia : 
I.  Diminution  in  urea  and  increase  in  uric  acid  excreted.  2.  The 
presence  of  extractives — /.  e.,  leucin,  tyrosin,  xanthin,  and  hypo- 
xanthin.  3.  Urobiluria,  peptonuria,  indicanuria,  and  albuminuria. 
4.  Glycosuria,  the  liver  being  unable  to  perform  its  complete  gly- 
cogenic function  if  considerable  glucose  be  taken  daily  in  the 
food.  Enlargement  or  tenderness  of  the  liver  may  sometimes 
be  felt.  In  extreme  toxic  cases  it  may  be  much  reduced  and 
destroyed. 

Jaundice. — Any  of  the  well-recognized  causes  of  this  condition 
may  produce  it  in  the  pregnant  woman.  Sometimes  it  appears  in 
the  late  months  as  the  result  of  an  exceptional  degree  of  increased 
intra-abdominal  pressure. 

Acute  Yellow  Atrophy. — This  affection  occurs  in  both 
sexes,  but  especially  in  women.     In  a  considerable  percentage  of 


300  AFFECTIONS   OF   THE   ALIMENTARY   TRACT. 

cases  it  affects  pregnant  women  and  is  frequent  in  the  early 
months. 

Its  etiology  is  unknown,  but  it  is  probably  associated  with  an 
invasion  of  the  bile  tracts  with  toxic  matter  from  the  intestines. 

The  symptoms  vary  considerably.  There  are  usually  premon- 
itory^ phenomena,  but  these  are  variable  ;  the}-  are  gastro-intestinal 
disorders — /.  c,  nausea,  vomiting,  loss  of  appetite,  furred  tongue, 
diarrhea,  constipation,  and  slight  pyrexia.  There  may  be  vague 
pains  or  uneasiness  in  the  epigastric  region,  which  may  last  days 
or  weeks.  Jaundice  develops,  as  a  rule,  gradually,  but  sometimes 
suddenly.  It  may  affect  only  the  upper  part  of  the  body  or  be 
more  extensive ;  it  is  not  usually  intense.  Vomiting  becomes 
more  and  more  marked  as  the  case  advances,  food,  mucus, bile,  or 
altered  blood  (like  "  black  vomit "  in  yellow  fever)  being  ejected. 
Constipation  ma}'  be  marked.  Sometimes  there  is  diarrhea  and 
the  stools  are  occasionally  bloody.  Pain  is  felt  in  the  region 
of  the  Hver,  and  the  area  of  hepatic  dulness  diminishes  as  the  liver 
atrophies.  Peritonitis  is  very  rarely  present.  Frequently  there 
are  muscle  and  joint  pains  ;  sometimes  the  joints  are  swollen.  The 
patient  is  restless  and  irritable  and  complains  of  headache.  As  the 
case  advances  there  may  develop  muttering  delirium,  subsultus, 
muscular  tremors  or  rigidity,  stupor,  coma,  convulsions,  retention 
or  incontinence  of  urine,  and  incontinence  of  feces. 

The  temperature,  while  usuall}-  slightly  elevated  in  the  early 
stages,  rarely  reaches  I0i°  F.  ;  in  the  late  stages  it  may  be  sub- 
normal. The  pulse  varies  ;  early  it  may  be  raised,  but  falls  when 
the  jaundice  appears  and  rises  when  cerebral  symptoms  develop. 
The  urine  is  dark,  often  containing  albumin  or  blood.  There  is 
diminution  of  urea,  uric  acid,  chlorids,  sulphates,  and  earthy  phos- 
phates. Leucin  and  tyrosin  are  formed  when  the  urine  stands. 
Hemorrhages  are  common  in  the  stomach,  bowels,  nose,  or  in  the 
subcutaneous  tissue  ;  occasionally  in  the  decidua  and  placenta. 
Premature  emptying  of  the  uterus  always  occurs  unless  the  mother 
dies  early.  The'  disease  is  almost  always  fatal  within  twenty-four 
hours  or  a  few  days. 

The  treatment  is  unsatisfactory.  The  action  of  the  skin,  kid- 
neys, and  intestines  must  be  assisted.  Stimulants  must  be  given 
freely.  Injections  of  normal  saline  solution  should  be  given  sub- 
cutaneously  or  per  rectum. 

Nausea  and  Vomiting. — These  disturbances  have  been 
described  as  they  ordinarily  occur  in  pregnancy,  being  universally 
recognized  as  reflex  neuroses,  unassociated  usually  with  any  definite 
pathologic  changes.     (See  p.  114.) 

Evans  has  advanced  the  hypothesis  that  the  rhythmical  con- 
tractions of  the  pregnant  uterus  are  the  primary  cause  of  the 
reflex  irritation  resulting  in  paroxysmal  nausea  and  vomiting. 
Some  authors  believe  that  increased  thyroid  secretion  is  the  cause 


PERNICIOUS    VOMITING.  3OI 

of  the  vomiting  of  pregnancy.  At  the  present  time  the  view  gains 
ground  that  an  important  factor  in  causing  these  disturbances, 
especially  the  severe  forms,  is  autointoxication  from  circulating 
toxins,  there  being  different  opinions  as  regards  the  production  of 
these  ;  it  is  often  noted  that  pregnant  women  in  whom  elimination 
is  active  rarely  suffer  from  gastric  or  other  disturbances.  It  is 
important  to  remember  that  vomiting  may  also  be  due  to  any  of 
the  causes  that  produce  the  disturbance  in  the  non-pregnant  state 
— /.  c,  organic  disease  of  the  stomach,  nephritis,  etc. 

Pernicious  Vomiting". — In  some  cases  the  vomiting  persists 
and  becomes  more  frequent,  the  stomach  being  unable  to  retain 
anything.  Straining  and  retching  are  intense.  The  vomit  con- 
tains food,  mucus,  bile,  and  in  advanced  cases  small  quantities  of 
blood.  Sometimes  there  is  diarrhea.  The  condition  is  usually 
worse  at  night  in  bad  cases.  Distress  and  pain  in  the  chest  and 
upper  abdominal  region  are  present,  and  there  is  sometimes  a 
cough.  The  patient  usually  takes  an  aversion  to  food,  complains 
of  thirst,  and  becomes  weakened,  emaciated,  and  depressed.  In 
the  advanced  stages  the  mouth  and  throat  become  dry,  the  breath 
offensive,  and  sordes  forms  on  the  teeth.  There  may  be  incon- 
tinence of  the  urine  and  feces.  The  extremities  become  cold  and 
clammy.  Small  extravasations  of  blood  may  occur  in  different 
parts.  The  pulse  becomes  weak,  rapid,  and  irregular.  The 
temperature  may  rise  as  high  as  103°  or  104°  F.  The  urine 
has  a  high  specific  gravity,  is  dark,  scanty,  and  contains  albumin, 
casts,  and  blood-corpuscles.  Later  the  weakness  becomes  marked 
and  there  may  be  attacks  of  cardiac  syncope.  There  may  be 
mental  disturbances — ''.  c,  stupor,  coma,  and  delirium.  In  some 
cases  the  disease  becomes  steadily  worse  ;  in  others  there  are  in- 
tervals in  which  the  condition  appears  to  improve.  If  the  patient 
be  not  well  nursed,  bedsores  and  ulceration  of  the  cornea  may 
develop.  The  worst  cases  usually  end  fatally  within  a  month ; 
many  continue  several  weeks  longer.  The  mortality  is  high, 
different  statistics  placing  it  at  30  to  60  per  cent.  Sometimes  the 
fetus  may  die  /;/  iitero.  This  may  or  may  not  be  followed  by 
cessation  of  vomiting. 

The  etiology  is  uncertain.  In  some  cases  the  vomiting  seems 
to  be  reflex  from  various  pelvic  disturbances — /.  t'.,  uterine  dis- 
placements, rigidity  and  stenosis  of  the  cervix,  inflammation  in  the 
uterus  or  its  adnexa,  or  in  other  tissues  in  the  pelvis.  In  some 
cases  no  lesion  can  be  made  out  and  the  disturbance  appears  to  be 
a  neurosis,  such  as  may  be  found  sometimes  in  non-pregnant 
hysteric  women.  It  is  possible  that  in  some  cases  the  vomiting 
may  be  due  to  the  influence  of  unknown  toxic  agents.  Certainly 
in  the  late  stages  many  of  the  signs  are  the  same  as  those  pro- 
duced by  toxins.  Cloudy  swelling  and  fatty  degeneration  are 
usually  found  in  various  organs — i.  e.,  liver  and  kidneys.     Linde- 


302  AFFECTIONS    OF   THE   ALIMENTARY   TRACT. 

mann  found  neuritis  in  some  cases  in  various  nerves — /.  r.,  phrenic, 
vagus,  median,  etc.  It  must  be  remembered  that  intense  vomiting- 
in  pregnancy  may  sometimes  be  due  to  organic  lesions,  such  as 
cerebral  tumors,  nephritis,  gastric  ulcer,  gastritis,  cancer  of  the 
stomach,  etc. 

Treatment. — Careful  examination  should  always  be  made  to 
determine  whether  any  definite  lesion  exists  that  might  cause  the 
vomiting — /.  c,  nephritis,  in  order  that  necessary  therapeutic 
measures  may  be  instituted.  Sometimes  a  patient  improves  after 
a  bimanual  examination  or  after  the  insertion  of  a  vaginal  tampon. 
A  retroverted  uterus  should  be  replaced  if  possible.  Inflammatory 
areas  on  the  cervix  may  be  swabbed  with  iodized  phenol  and  warm 
formalin  douches  (TTlxx-Oj),  taken  twice  daily.  Nabothian  cysts 
should  be  punctured.  When  there  are  intrapelvic  inflammatory 
conditions,  vaginal  tampons  of  ichthyol  glycerin  (1:15)  may  be 
used.  A  series  of  blisters  in  the  iliac  regions  are  sometimes 
beneficial.  If  the  cervix  be  stenosed  and  rigid  it  may  be  dilated 
somewhat,  though  this  procedure  should  be  postponed  as  long  as 
possible,  owing  to  the  risk  of  causing  abortion.  It  is  recom- 
mended by  some  that  dilatation  be  accompanied  with  stripping 
of  the  membranes  for  a  slight  distance  above  the  cervix.  Where 
no  definite  lesion  can  be  made  out,  treatment  on  hygienic,  dietetic, 
and  medicinal  lines  must  be  adopted.  Bearing  in  mind  the  part 
that  ma)^  be  played  by  toxins,  eveiy  effort  should  be  made  to 
promote  elimination.  The  importance  of  exercising  a  strong 
psychical  influence  over  the  patient  must  always  be  remembered. 
Sometimes  a  brilliant  cure  may  be  effected  by  suggestive  thera- 
peutics. Tibone  has  advocated  the  subcutaneous  injection  of 
hydrochlorate  of  cocain  in  the  hypogastrium.  This  has  also 
been  recommended  by  Pozzi. 

Sexual  intercourse  should  be  stopped  and  all  causes  of  excite- 
ment or  distress  avoided.  In  bad  cases  the  woman  should  be  put 
to  bed  and  carefully  nursed.  Small  quantities  of  easily  digested 
or  predigested  foods — /.  c,  pancreatized  milk,  liquid  peptonoids, 
peptonized  beef  tea,  beef  juice,  etc.,  should  be  given  at  regular  in- 
tervals. Sometimes  a  patient  may  retain  some  special  article  of  diet 
that  she  strongly  desires.  Sometimes  small  quantities  of  alcoholic 
beverages  may  be  retained.  Food  may  sometimes  be  satisfactorily 
retained  if  the  fauces  be  previously  sprayed  with  cocain,  or  if  it 
be  introduced  into  the  stomach  through  a  tube.  Sometimes  re- 
peated small  doses  of  sodium  bicarbonate  are  helpful.  Lavage 
of  the  stomach  is  sometimes  beneficial.  When  these  measures 
fail  nutrient  enemata  must  be  given  (4  or  5  oz.  in  each).  With 
these  a  patient  may  be  fed  several  weeks.  A  high  enema  of 
normal  saline  solution,  given  in  addition  two  or  three  times  each 
day,  helps  to  relieve  thirst  and  dilutes  circulating  toxins  as  well 
as  stimulates  renal  activity.     When  the   patient  needs  alcoholic 


ACUTE   FEBRILE   DISEASES.  303 

stimulants  that  cannot  be  given  by  the  stomach,  they  may  be 
added  to  the  enemata. 

As  to  medicinal  treatment  not  much  is  to  be  said  ;  there  is  no 
true  specific.  Various  drugs  have  been  recommended — c.  g., 
cerium  oxalate,  iodin,  bismuth,  dilute  hydrocyanic  acid,  menthol, 
etc.  Strychnin  is  valuable  when  cardiac  stimulation  is  necessary. 
Various  sedatives  may  be  required — e.  g.,  sodium  bromid,  chloral, 
and  codein.  Morphin  should  only  be  used  in  extreme  cases  to 
quiet  the  patient  and  to  cause  her  to  sleep.  These  drugs  may  be 
given  in  the  enemata  when  the  stomach  will  not  retain  them. 
Mustard  poultices  over  the  epigastrium  sometimes  act  beneficially. 

Finally,  when  the  patient  grows  worse  afi:er  careful  treatment 
on  the  above-mentioned  lines  has  been  tried,  the  uterus  should  be 
emptied.  This  procedure  usually  succeeds  in  checking  the  vomit- 
ing, but  it  may  sometimes  fail.  While  this  should  only  be  under- 
taken as  a  last  resort,  it  should  not  be  postponed  too  long  lest  the 
patient  be  too  weak  to  recover  from  the  operation. 


CHAPTERVII. 

ACUTE   FEBRILE  DISEASES. 

Influenza. — Pregnant  women  enjoy  no  immunity  from  this 
disease.  It  may  rarely  cause  premature  expulsion  of  the  ovum. 
In  a  few  cases  postpartum  hemorrhage  has  been  reported. 

Cholera. — Premature  emptying  of  the  uterus  is  frequent  in 
this  disease,  the  causal  factors  being  the  poisons  circulating  in  the 
blood,  hemorrhages  into  the  placenta,  and  the  mechanical  irrita- 
tion of  purging  and  vomiting.  According  to  Schiitz,  the  tendency 
to  interruption  of  pregnancy  is  greater  the  later  in  gestation  the 
patient  is  attacked.  The  disease  is  very  fatal  to  the  fetus  in  any 
stage.  The  patient  frequently  dies  before  abortion  occurs.  If 
labor  starts  it  should  be  completed  artificially,  as  the  pains  are 
apt  to  be  weak.  Frequently  a  child  born  at  or  near  term  dies 
within  a  few  days  of  birth. 

Typhoid. — This  disease  is  not  believed  to  be  more  dangerous 
to  the  pregnant  than  to  the  non-pregnant  woman,  but  the  effects 
on  the  fetus  are  very  serious.  In  about  65  per  cent,  of  cases, 
according  to  Duguyot,  it  is  expelled  prematurely.  This  is  due  to 
the  high  temperature,  the  alteration  of  the  blood,  hemorrhages 
into  the  decidua  or  placenta,  and  in  some  cases  the  direct  trans- 
mission of  the  disease  to  the  fetus.     The  fetus  may  be  born  dead 


304  ACUTE  FEBRILE  DISEASES. 

or  alive,  and  in  it  typhoid  bacilli  may  be  found,  or  its  blood  may 
^\sr&  the  Widal  reaction.  When  it  does  not  die  it  is  likely  to 
develop  into  a  weakly  infant. 

In  the  treatment  of  this  disease  Vinay  and  others  advocate 
strongly  the  cold-bath  treatment.  He  reports  the  maternal  mor- 
tality as  being  6  per  cent.,  whereas  w^hen  the  bath  is  not  used  it  is 
17  per  cent.  The  bath  treatment  only  slightly  lessens  the  tendency 
to  abortion.  It  should  be  employed  after  this  complication  as 
long  as  the  temperature  is  high. 

Abortion  and  labor  do  not  aggravate  the  disease,  according  to 
Vinay  and  Brand.  They  point  out,  however,  that  typhoid  starting 
in  the  puerperium  has  a  very  high  mortality,  50  per  cent,  in  a 
series  of  cases  collected  by  Vinay. 

Lynch  has  recently  made  a  study  of  reported  cases  of  typhoid 
in  pregnancy  and  arriv^es  at  the  following  conclusions  :  That  the 
typhoid  bacillus  may  pass  from  the  mother  to  the  child  in  ntero  ; 
that  the  resulting  disease  is  a  fetal  septicemia  ;  in  cases  of  pla- 
cental transmission  there  are  generally  placental  lesions  of  a  hem- 
orrhagic type ;  that  the  child  dies  either  in  2itcro  or  soon  after 
birth  ;  and  there  is  no  evidence  that  the  fetus  may  survive  the 
infection  /;/  ittero  ;  placental  transmission  is  not  the  rule  in  typhoid  ; 
the  Widal  reaction  is  not  alwa}'s  given  with  fetal  blood,  even 
though  placental  transmission  be  proved,  and  when  present  it 
cannot  be  determined  whether  the  agglutinating  substances  result 
from  the  presence  of  the  typhoid  bacilli  or  whether  they  have 
filtered  through  the  placenta  from  the  mother's  blood ;  the  ag-. 
glutinating  substances  may  be  transmitted  through  the  milk  of  a 
typhoid  mother  to  her  nursling.  The  reaction  in  the  nursling's 
blood  is  but  transient,  and  is  always  weaker  than  that  of  the 
mother's. 

Typhus. — This  disease  is  not  aggravated  by  pregnancy.  There 
is  less  tendency  to  abortion  than  in  typhoid,  probably  because 
intra-uterine  hemorrhages  are  less  frequent. 

Scarlatina. — Pregnancy  is  believed  by  some  to  prolong  the 
incubation  period  of  this  disease,  because  a  w^oman  exposed  to 
the  risk  of  infection  may  pass  through  her  pregnancy  and  not 
take  the  disease  until  the  lying-in  period.  In  such  cases  the  ex- 
planation is  rather  that  the  disease  develops  because  her  power 
of  resistance  is  diminished  by  the  exhaustion  of  labor.  When 
the  disease  develops  in  pregnancy  premature  emptying  of  the 
uterus  is  common.  The  fetus  may  contract  the  disease  in  utcro 
and  present  well-marked  signs  at  birth,  though  in  some  cases  it 
escapes.  Sometimes  the  mother  may  have  a  very  slight  attack 
and  the  fetus  a  severe  one.  The  skin  of  the  latter  may  desquamate 
in  ntcro  or  after  birth. 

Malaria. — Pregnancy  is  said  to  modify  the  character  and 
periodicity  of  the  malarial  attacks.     Abortion  may  be  caused  chiefly 


MEASLES— SMALL-POX.  305 

by  hemorrhages  in  utero.  Negri  found  this  in  18  per  cent,  of  his 
cases.  Various  authors  state  that  the  disease  may  affect  the  fetus, 
causing  periodic  disturbances,  while  it  is  in  the  uterus  or  soon 
after  birth,  though  it  is  doubtful  if  the  plasmodium  has  been  found 
in  the  fetal  blood.  The  development  of  the  fetus  is  interfered  with 
by  the  malarial  poison.  Quinin  should  always  be  administered  to 
the  pregnant  woman  affected  with  this  disease. 

Maggi  has  recently  reported  20  cases  in  which  this  drug  was 
freely  administered  without  causing  abortion,  the  condition  of  the 
patients  being  markedly  improved  and  the  infants  being  born 
healthy  and  robust ;  the  drug  was  given  in  the  form  of  intra- 
muscular injections  of  the  bichlorid. 

Measles. — This  disease  causes  abortion  in  a  large  percentage 
of  cases.  Rarely  the  fetus  may  be  affected  in  iitero  and  present 
signs  at  birth,  or  may  develop  them  a  few  days  afterward. 

Small-pox. — Pregnancy  is  very  frequently  interrupted  in  the 
course  of  an  attack  of  small-pox.  According  to  Voigt,  half  the 
cases  of  pregnancy  in  women  suffering  from  small-pox,  who  have 
been  vaccinated  in  youth  end  prematurely.  The  mortality  of  such 
cases  varies  from  30  to  35  per  cent. ;  it  is  higher  among  those  who 
have  never  been  vaccinated.  Hemorrhagic  and  confluent  small- 
pox are  much  more  frequent  in  pregnant  than  in  non-pregnant 
cases.  Voigt  states  that  about  60  per  cent,  of  women  delivered 
while  suffering  from  small-pox  die.  In  some  cases  the  fetus 
may  have  the  disease  in  zitero  and  may  perish  as  a  result.  It 
may  go  to  term  and  show  signs  of  small-pox  or  it  may  be  born 
immune.  In  most  cases,  however,  the  fetus  is  not  infected,  though 
it  usually  dies  at  or  soon  after  birth.  There  are  marked  variations 
in  its  susceptibility  to  attack.  Sometimes  in  the  case  of  twins  one 
may  suffer  and  the  other  escape.  It  is  possible  for  the  fetus  to 
have  the  disease,  the  mother  escaping.  A  pregnant  woman  should 
always  be  vaccinated  in  epidemics.  The  effect  on  the  fetus  varies. 
Behm  has  reported  33  cases  in  which  vaccination  was  carried  out 
during  pregnancy,  the  children  being  also  vaccinated  after  birth  ; 
in  the  latter  there  were  25  successful  results.  Wolff  states  that  he 
has  always  been  able  to  vaccinate  the  children  of  women  vaccinated 
in  pregnancy.  Chambrelent  had  7  cases,  in  which  only  3  children 
were  successfully  vaccinated.  Ballantyne  believes  that  i  fetus  in 
3  is  protected  by  vaccination  in  the  second  half  of  gestation. 
Maude,  from  a  study  of  cases  in  England,  states  that  the  child  was 
rendered  insusceptible  if  the  mother's  vaccination  took  place  before 
the  sixth  month  ;  that  during  the  sixth  and  seventh  months  the 
protection  afforded  to  the  child  is  doubtful ;  and  that  after  the 
seventh  month  no  protection  at  all  is  produced.  Fulton  points 
out  that  the  period  of  protection,  however  complete,  is  very  short, 
all  or  nearly  all  the  infants  giving  some  reaction  to  vaccination 
after  eighteen  months  or  two  years.  Shuter  reports  a  case  in 
20 


306  ACUTE  FEBRILE  DISEASES. 

which  protection  was  afforded  when  the  mother  had  been  vacci- 
nated immediately  before  conception. 

In  the  interests  of  the  child  it  is  always  advisable  to  vaccinate 
it  after  birth  if  the  mother  has  had  the  disease  during  pregnancy 
or  if  there  is  an  epidemic. 

i^rysipelas. — This  disease,  if  severe,  may  cause  premature 
emptying  of  the  uterus.  This  is  a  serious  complication,  since  the 
infection  may  attack  the  genital  tract.  The  fetus  may  suffer  from 
the  disease  in  titei'o,  streptococci  being  found  in  it,  but  this  is  a 
rare  occurrence. 

Diphtheria. — This  disease  may  cause  premature  expulsion  of 
the  ovum,  an  occurrence  attended  with  great  risk  on  account  of 
the  liability  of  the  genital  tract  to  infection.  The  specific  organ- 
ism has  sometimes  been  found  in  the  tissues  of  the  fetus. 

Rheumatic  Pever. — This  is  a  very  rare  affection  in  preg- 
nancy, the  latter  state  increasing  its  seriousness.  There  is  a  greater 
risk  of  thrombosis  and  of  the  formation  of  vegetations  on  the 
heart  valves.  Abortion  may  be  caused.  Rarely  the  fetus  is  also 
affected  with  the  disease. 

Septicemia. — General  septic  infection  of  a  pregnant  woman, 
if  not  fatal  to  her,  may  cause  death  of  the  fetus  and  emptying  of 
the  uterus.  There  is  no  doubt  that  the  micro-organisms  may  pass 
from  the  maternal  tissues  into  the  fetus. 

Tuberculosis. — The  relationship  of  pregnancy  to  pulmonary 
consumption  has  been  noted.  Direct  transmission  of  tuberculosis 
from  the  mother  to  the  fetus  is  a  very  rare  occurrence.  Experi- 
mentally the  inoculation  of  pregnant  animals  has  exceptionally  led 
to  the  passage  of  tubercle  bacilli  into  the  fetal  tissues.  It  is  more 
likely  to  occur  in  the  human  subject  if  the  mother  is  affected  with 
extensive  and  rapidly  advancing  tuberculosis.  The  ovum  is  prob- 
ably not  affected  before,  but  after,  conception,  when  the  chorion 
enters  into  relationship  with  the  maternal  blood,  the  tubercle 
bacilli  passing  through  the  placenta.  There  is  no  certain  proof 
that  the  semen  from  a  tuberculous  father  has  ever  caused  fetal 
tuberculosis.  The  children  of  tuberculous  parents  frequently 
present  malformations  or  structural  peculiarities. 


SYPHILIS.  307 

CHAPTER    VIII. 

SYPHILIS. 

Syphilis  is  found  in  various  relationships  to  pregnancy. 

I.  Acute  Primary  Syphilis. — {a)  At  or  Near  the  Time  of 

the  Fruitful  Intercourse. — The  local  manifestations  vary  in  differ- 
ent cases  ;  they  are  sometimes  slight,  but  may  be  very  marked. 
There  may  be  much  swelling,  redness,  and  irritation  ;  excoriation 
may  be  present,  and  sometimes  there  maybe  sloughing  or  abscess 
formation.  Frequently  no  distinct  hard  area  is  noticeable,  or  may 
be  present  only  for  a  short  time.  The  mother's  health  often 
deteriorates  considerably.  The  ovum  becomes  affected  and  abor- 
tion is  frequent.  Gestation  may  in  some  cases  continue  several 
months  before  terminating ;  occasionally  full  time  is  reached,  the 
child  being  born  in  a  weak  condition  with  a  syphilitic  taint,  which 
soon  becomes  manifest,  generally  causing  death. 

ib)  In  the  Early  Months. — When  a  pregnant  woman  contracts 
a  primary  sore  in  the  early  months  abortion  may  occur ;  but  more 
frequently  premature  labor  takes  place  in  the  late  months,  or  the 
child  is  born  at  full  time  with  congenital  syphilis. 

{c)  Late  in  Pregnancy. — When  the  woman  gets  the  disease  in 
advanced  gestation  labor  usually  occurs  at  full  time.  The  child 
may  or  may  not  have  contracted  syphilis  ///  utero,  but  it  may 
become  inoculated  by  contact  with  the  infected  area  on  the  maternal 
parts  during  birth. 

II.  Secondary  or  Tertiary  Maternal  Syphilis. — When  a 
woman  presenting  signs  of  past  syphilis  becomes  pregnant  the 
ovum  becomes  affected,  except  occasionally  when  she  has  very 
late  tertiary  signs.  Abortion  or  premature  labor  may  occur,  or 
the  child  may  be  born  at  full  time  with  a  taint  that  may  manifest 
itself  within  a  few  weeks  of  birth,  or  sometimes  only  after  months 
or  years.  If  pregnancy  be  interrupted  and  successive  gestations 
follow  the  same  result  ensues  unless  treatment  be  carried  out, 
though  the  interruption  tends  to  occur  at  later  periods. 

HI.  Secondary  Syphilis  in  the  Husband. — When  a  woman 
is  impregnated  by  a  man  who  has  secondary  syphilis  she  may  by 
accident  be  directly  infected  from  him — /.  e.,  through  a  mucous 
patch.  In  most  cases  such  an  infection  does  not  occur.  The  ovum 
becomes  affected  and  pregnancy  is  interrupted  in  the  early  months 
or  after  midterm.  Through  the  ovum  the  mother  may  become 
diseased,  and  in  some  cases  she  may  exhibit  one  or  more  of  the 
well-known  signs — /.  c,  sore  throat,  loss  of  hair,  eruptions,  etc. 
In  some  cases  these  may  be  so  slight  as  to  escape  her  observa- 
tion, or  they  may  be  entirely  absent.  She  may  thus  early  acquire 
a  state  of  constitution  that  [protects  her,  so  that  she  cannot  after- 


308  SYPHILIS. 

ward  contract  syphilis  (Colles's  law).  The  nature  of  this  change 
is  not  well  understood.  It  probably  consists  in  a  passage  through 
the  placenta  of  products  from  the  fetus,  capable  of  immunizing  the 
maternal  system  without  actually  inducing  syphilis.  Indeed,  these 
cases  prove  that  the  immunizing  material  may  pass  from  the  fetal 
to  the  maternal  circulation,  and  that  the  actual  syphilitic  virus 
does  not  pass  or  is  ineffectual.  In  some  instances  the  woman  is 
not  immunized  and  is  capable  of  being  syphilized  after  her  preg- 
nancy. Why  in  other  cases  she  should  actually  be  infected  with 
syphiHs  from  the  ovum  is  uncertain.  It  ma)'  be  due  to  some 
alteration  in  the  vilH  whereby  the  poison  is  able  to  pass  through 
them.  Veit  has  recently  suggested  that  the  maternal  infection 
may  arise  from  portions  of  the  villi  that  may  become  detached  and 
enter  the  maternal  circulation.  The  immunized  mother  may  nurse 
her  child  with  impunity,  whereas  a  healthy  wet-nurse  may  be  in- 
fected by  nursing  such  a  syphilitic  infant. 

As  regards  the  ovum  in  successive  pregnancies,  its  expulsion 
tends  to  occur  at  later  and  later  periods,  until  finally  a  full-time 
delivery  takes  place,  the  child  being  born  in  a  feeble  and  diseased 
state.  Occasionally  in  these  cases  pregnancy  may  be  interrupted 
at  successively  earlier  periods  and  not  at  later  ones.  The  reason 
of  this  peculiarity  is  not  known.  A  woman  who  has  been  im- 
munized through  the  influence  of  the  ovum  may  bear  healthy 
children  to  a  healthy  man.  There  is  some  doubt  as  to  whether 
in  some  cases  the  ovum  may  not  be  affected. 

IV.  Tertiary  Syphilis  in  the  Husband. — In  the  majority 
of  cases  neither  wife  nor  child  is  affected  when  two  or  more  years 
have  elapsed  after  the  disappearance  of  the  secondary  phenomena. 
In  some  instances  this  is  not  the  case,  and  the  child  may  be  born 
with  inherited  syphilis,  occasionally  prematurely.  The  factors 
that  explain  these  variations  are  not  well  understood.  It  is  to  be 
noted  in  general  that  a  child  has  a  better  chance  of  escaping  if 
the  father  has  tertiary  syphilis  than  if  the  mother  is  thus  affected. 

V.  Syphilis  in  both  Parents. — When  father  and  mother 
are  syphilitic  the  risk  to  the  fetus  is  greater,  the  mortality  being 
very  high.  As  regards  the  manifestations  of  syphiUs  in  the  fetus, 
there  are  probably  no  differences  depending  upon  the  stage  of  the 
disease  in  one  or  the  other  parent.  With  succeeding  pregnancies 
there  is  a  general  tendency  to  the  lessening  of  the  effects  of  the 
syphilitic  poison.  In  the  case  of  a  series  of  children,  the  older 
usually  have  a  more  marked  inheritance  than  the  younger,  but 
sometimes  the  latter  may  be  as  seriously  affected  as  the  former. 
In  some  instances  there  is  an  irregular  distribution  of  the  inherited 
disease.  One  child  may  escape  entirely  or  may  be  only  slightly 
affected  and  the  next  one  may  be  markedly  tainted.  Sometimes 
in  the  case  of  twins  one  may  be  diseased  and  the  other  remain 
free. 


SYPHILIS  IN  BOTH  PARENTS.  309 

With  regard  to  the  question  of  marriage,  it  must  be  remem- 
bered that  there  is  a  risk  that  the  syphihtic  taint  may  exhibit 
itself  years  after  the  period  of  primary  infection,  and  that  the 
effect  on  offspring  can  never  be  predicted  with  absolute  certainty. 
Though  it  may  be  urged  that  the  syphilitic  should  not  marry,  the 
advice  has  little  influence,  and  it  is  necessary  to  warn  those  who 
contemplate  taking  this  step  and  who  ask  for  a  medical  opinion, 
in  order  that  the  risks  should  be  diminished  as  much  as  possible. 
A  diseased  person  should  not  marry  until  three  or  four  years  have 
elapsed  from  the  time  of  the  primary  infection,  and  until  all  sec- 
ondary symptoms  have  been  absent  two  years.  The  individual 
should  have  had  a  thorough  course  of  mercurial  treatment.  If 
there  are  cerebral  symptoms  or  serious  organic  changes  marriage 
should  not  take  place. 

Treatment. — When  advice  is  sought  because  of  premature 
emptying  of  the  uterus  or  the  birth  of  diseased  children,  concep- 
tion should  not  be  allowed  to  take  place,  and  the  parents  should 
be  put  on  a  course  of  mercurial  treatment  until  all  symptoms 
have  disappeared,  if  any  have  been  present,  and  pregnancy  should 
not  take  place  until  two  years  have  passed  after  the  last  one. 
When  conception  does  again  occur  the  woman  should  be  carefully 
watched.  It  is  advisable  to  administer  potassium  chlorate  and 
iron  if  she  tends  to  become  anemic.  A  mercury  salt  may  also  be 
given  in  small  doses,  or,  if  this  does  not  agree  with  the  woman, 
iodid  of  potassium  may  be  substituted. 

With  such  care  a  healthy  child  may  be  obtained.  Sometimes 
this  happy  result  is  not  brought  about,  and  it  is  then  necessary  to 
subject  both  parents  to  another  thorough  course  of  treatment 
In  cases  where  pregnancy  is  discovered  in  a  woman  with  primary 
or  secondaiy  syphilis  she  should  be  placed  on  a  vigorous  course 
of  treatment,  mercury  being  freely  used.  Local  sores  should  be 
made  well  as  rapidly  as  possible  in  order  to  diminish  the  risk  of 
infection  of  the  child  during  delivery.  When  a  living  child  is 
born  it  must  only  be  nursed  by  the  mother  and  not  by  a  wet- 
nurse,  because  of  the  possibility  of  infection  of  the  latter.  If  it 
develop  any  symptoms  of  syphilis  it  must  be  treated  by  the  in- 
unction of  mercury. 


310  AFFECTIONS   OF   THE    URINARY  SYSTEM. 

CHAPTER    IX. 

AFFECTIONS  OF  THE  URINARY  SYSTEM. 

Incontinence  and  Frequency  of  Micturition. — In  the 

early  months  of  pregnancy  frequency  of  micturition  is  often  present 
as  a  result  of  the  pressure  of  the  growing  uterus  on  the  bladder. 
This  is  most  marked  when  there  is  some  prolapse  of  the  uterus 
or  adjacent  structures.  In  troublesome  cases  a  suitable  vaginal 
pessary  may  bring  about  improvement.  It  should  always  be  re- 
membered that  frequency  of  micturition  in  early  pregnancy  may 
be  associated  with  retroversion  of  the  gravid  uterus,  the  bladder 
being  really  overdistended  while  dribbling  takes  place  from  it.  In 
the  late  weeks,  especially  in  multiparas,  frequency  of  urination 
may  be  present  as  the  result  of  increasing  pressure  of  the  uterus 
on  the  bladder.  In  women  with  very  lax  abdominal  walls,  whose 
recti  are  much  separated,  there  may  be  continued  dribbling  of 
urine  on  the  slightest  exertion.  This  is  aggravated  by  a  weak 
condition  of  the  pelvic  floor.  It  may  also  be  caused  by  an  un- 
usual relationship  of  the  fetus  to  the  uterus — i.  c,  when  it  lies 
obliquely  or  transversely.  Incontinence  in  pregnancy  may  also 
be  due  to  other  conditions  that  may  cause  it  in  non-pregnant 
women. 

Retention. — This  is  much  less  frequent  than  incontinence  in 
pregnancy.  It  may  occur  with  retroversion  of  the  uterus,  as  the 
result  of  pressure  of  the  cervix  against  the  pubes.  It  may  also 
be  due  to  the  pressure  of  tumors.     Sometimes  it  is  a  neurosis. 

Cystitis. — This  condition  may  be  very  troublesome.  If  it  be 
acute  there  is  great  risk  of  an  infection  of  the  uterus  and  kidneys. 
In  connection  with  retroversion  of  the  gravid  uterus,  cystitis  may 
be  very  severe;  the  inner  part  of  the  bladder-wall  may  become 
gangrenous  and  may  slough  away. 

In  the  treatment  of  cystitis  absolute  rest  is  advisable,  while 
the  ordinary  measures  are  adopted  to  check  the  disease. 

Diabetes  Insipidus  or  Polyuria. — Occasionally  a  woman 
is  troubled  by  the  passage  of  large  quantities  of  urine  of  low 
specific  gravity  during  weeks  or  months  of  her  pregnancy.  She 
complains  of  thirst  and  has  a  dry  skin.  The  cause  of  this  dis- 
turbance is  not  known.  It  usually  passes  off  after  delivery. 
Sometimes  it  causes  premature  delivery. 

Peptonuria. — Peptones  are  sometimes  found  in  the  urine  in 
pregnancy.  It  has  been  stated  that  they  indicate  death  of  the 
fetus,  but  they  may  be  found  while  it  is  living. 

Hematuria  ma}-  be  sometimes  due  to  vesical  hemorrhoids, 
but  it  is  also  produced  by  other  conditions  that  may  be  found  in 


CHANGES   m   THE   KIDNEYS  DURING   PREGNANCY.      3II 

the  non-pregnant  state.  It  has  been  reported  in  a  few  cases  as 
being  due  to  renal  disturbance,  passing  off  after  dehvery,  and 
sometimes  recurring  in  a  subsequent  pregnancy. 

Glycosuria. — Reference  has  already  been  made  to  the  occur- 
rence of  sugar  in  the  urine  in  pregnancy.  Statistics  vary  greatly 
as  regards  the  frequency — 2  to  30  per  cent.  In  the  great  majority 
of  cases  the  glycosuria  is  due  to  milk  sugar  absorbed  from  the 
breasts.  This  lactosuria  is  mainly  found  toward  the  end  of  gesta- 
tion.     It  is  more  frequent  after  delivery. 

Diabetes  MellitUS. — This  disease,  in  which  glucose  exists 
in  the  urine,  may  be  present  before  pregnancy.  It  is  not  to  be 
regarded  as  favoring  sterility.  It  is  no  more  frequent  in  pregnant 
than  in  non-pregnant  women.  In  53  cases  of  diabetes  in  females, 
Griesinger  found  that  only  2  were  pregnant ;  Frerichs  found  i  in 
104  cases.  The  disease  may  disappear  after  labor  and  develop  in 
a  succeeding  pregnancy,  but  sometimes  it  does  not  cease.  It 
may  be  aggravated  by  pregnancy  and  the  mother  may  die,  the 
danger  being  greatest  in  the  late  months.  Fatal  cases  are  more 
frequent  in  the  puerperium.  The  fetus  is  apt  to  perish  and  to  be 
expelled  prematurely.  Sometimes  it  is  also  affected  with  the  dis- 
ease. Sugar  and  sometimes  acetone  may  be  found  in  the  liquor 
amnii.     Hydramnios  is  sometimes  found. 

The  treatment  is  the  same  as  in  the  non-pregnant  state.  If 
the  condition  cannot  be  improved  and  tends  to  become  worse  it  is 
best  to  empty  the  uterus. 

Changes  in  the  Kidneys  during-  Pregnancy. — For 
many  years  there  has  been  much  discussion  as  to  the  alterations 
occurring  in  the  kidneys  during  pregnancy,  and  at  the  present 
time  there  is  considerable  difference  of  opinion  as  to  the  nature 
of  these  changes,  their  frequency,  causation,  and  significance. 
The  literature  of  the  subject  is  abundant  in  speculative  inquiries, 
while  records  of  trustworthy  facts  derived  from  careful  and  sys- 
tematic observation  are  scanty.  Indeed,  though  theories  have 
multiplied,  it  is  doubtful  whether  we  are  much  wiser  than  we  were 
fifty  years  ago,  for  the  latest  and  most  favored  views,  originating 
among  French  workers,  are  only  an  elaborated  expression  of  the 
opinion  published  by  Virchow  in  1848. 

This  authority  then  pointed  out  that  of  all  the  organs  in  the 
female  organism  the  most  frequent  functional  or  structural  altera- 
tions due  to  pregnancy  were  found  in  the  kidneys.  He  regarded 
the  cause  mainly  as  connected  with  altered  metabolism,  changes 
being  induced  not  only  in  the  kidneys,  but  in  the  liver,  spleen, 
and  other  parts.  In  association  with  these  alterations  he  pointed 
out  the  frequency  of  albuminuria. 

That  the  kidney  becomes  somewhat  hypertrophied  as  a  result 
of  pregnancy  most  are  agreed,  though  the  nature  of  the  enlarge- 
ment  and   range  of  variations   are   not  at  all  definitely  known. 


312  AFFECTIONS   OF  THE    URINARY  SYSTEM. 

The  quantity  of  urine  is  increased  and  is  of  a  lower  specific 
gravity. 

With  regard  to  the  occurrence  of  albumin  in  the  urine  and  its 
significance  there  is  an  amazing  difference  of  opinion.  Its  fre- 
quency has  been  variously  estimated  by  different  workers.  The 
following  statistics  are  given  by  different  German  authorities : 
Meyer,  in  76  parturient  women,  found  albumin  in  40.78  per  cent. ; 
Litzmann,  in  100  parturient  women,  found  it  in  43.7  per  cent.  ; 
Lohlein,  also  in  100  parturient  women,  found  it  in  37  per  cent.; 
Flaischen,  in  537  parturient  women,  found  it  in  16.9  per  cent.; 
and  Winckel,  in  367  parturient  women,  found  it  in  19.4  per  cent. 
Trantenroth  states  that  in  50  per  cent,  of  pregnant  women  slight 
albuminuria  is  present  during  the  second  half  of  gestation,  and 
that  in  labor  it  is  the  rule. 

These  percentages  are  noticeably  higher  than  those  given  by 
leading  French  obstetricians.  Thus,  Pinard  states  that  out  of 
1249  parturient  women  in  the  Baudelocque  CUnic  in  1890  only 
73  cases  of  albuminuria  (6  per  cent.)  occurred :  of  these  slightly 
less  than  3  per  cent,  were  associated  with  pregnancy,  the  rest  with 
labor.  Charles  has  found  albuminuria  in  2.5  per  cent,  of  preg- 
nant women. 

So  far  as  may  be  gathered  from  more  recent  observations,  it 
may  be  stated  that  serum  albuminuria  occurs  in  about  2  per  cent, 
of  all  pregnant  women  who  are  health}'  at  the  beginning  of  preg- 
nancy. The  process  of  labor  causes  albuminuria  in  a  still  larger 
percentage  of  cases.  Aufrecht  found  it  was  produced  in  18  out 
of  32  women  examined;  Ingerslev,  in  50  out  of  153  cases  of 
labor.  It  is  most  frequent  in  women  during  the  first  pregnancy^ 
especially  in  those  who  are  no  longer  young  or  in  those  who  are 
ver}'  young.  Of  all  cases  it  is  believed  to  be  most  associated 
with  the  presence  of  more  than  one  fetus  in  utero.  It  occurs 
mainly  in  advanced  pregnancy,  only  rarely  in  the  early  months. 
According  to  Blaudeau,  albuminuria  is  most  frequent  in  first, 
second,  and  third  gestations,  becoming  much  rarer  in  succeeding 
ones.  He  studied  a  number  of  multiparae  in  whom  albuminuria 
had  occurred  in  previous  pregnancies.  In  8  out  of  23  cases  it 
recurred,  though  in  a  less  marked  degree  ;  in  2  only  was  it  worse. 

What  is  the  significance  and  explanation  of  this  albuminuria 
in  pregnancy?  Is  it,  as  some  hold,  a  physiologic  process  of  no 
importance,  or  is  it  to  be  regarded,  as  many  authorities  consider 
it,  as  the  result  of  pathologic  changes  induced  in  the  cortical  por- 
tions of  the  kidneys  ?  In  favor  of  the  former  view  may  be  adduced 
the  cases  of  healthy  men  and  non-pregnant  women  in  whom  a 
temporary  albuminuria  may  be  caused  by  various  factors — /.  e., 
changes  in  temperature,  food,  exercise,  etc.  The  investigations  of 
the  late  Grainger  Stewart  and  others  undoubtedly  appear  to  justify 
the  view  that  there  may  be  an  albuminuria  that  is  to  be  regarded 


CHANGES   IN   THE   KIDNEYS  DURING   PREGNANCY.      313 

as  a  physiologic  peculiarity  and  not  the  indication  of  a  pathologic 
process.  A  priori^  then,  it  must  be  conceded  that  a  like  expla- 
nation may  suffice  for  some  cases  of  the  albuminuria  in  pregnancy. 

Regarding  the  view  that  a  morbid  process  in  the  cortices  of  the 
kidneys  is  the  essential  cause,  the  following  facts  may  be  stated : 
In  very  many  cases  of  albuminuria  other  signs  of  renal  disease 
may  be  present.  Thus,  edema  may  be  frequently  met.  Winckel's 
statistics  may  be  noted:  In  1874,  in  319  pregnant  women,  he 
noted  edema  in  20  per  cent. ;  in  1876,  in  1058  pregnant  and  par- 
turient women,  in  4.35  percent.;  in  1877,  in  1091  pregnant  and 
parturient  women,  in  6.96  per  cent.,  and  in  1878,  in  1050  pregnant 
and  parturient  women,  in  5.52  per  cent.  Leyden  is  of  the  opinion 
that  anasarca  is  much  more  common  than  albuminuria,  and  that 
when  they  coexist  the  edema  has  appeared  first.  Then  again 
there  is  often  a  deficiency  in  the  quantity  of  urine  passed  and  in 
the  total  solids  excreted.  But  most  important  of  all  is  the  occur- 
rence in  the  urine  of  various  formed  elements — viz.,  casts  and 
blood-corpuscles.  Fischer,  who  has  given  much  attention  to  this 
subject,  points  out  that  these  are  mostly  found  in  the  last  weeks 
of  pregnancy,  when  they  often  show  progressive  increase.  Hyaline 
casts  are  frequent,  while  granular  and  epithelial  ones  and  broken- 
down  epithelium  may  also  occur.  Red  blood-corpuscles  and 
leukocytes  may  be  passed  continuously  or  at  intervals.  Now,  as 
to  the  relationship  between  the  above  findings  of  physical  exami- 
nation on  the  living  subject  and  those  obtained  by  postmortem 
investigation,  it  is  impossible  to  speak  with  absolute  certainty.  The 
great  majority  of  such  patients  do  not  die,  and  comparatively  only 
a  small  number  of  postmortem  studies  have  been  made.  There 
can,  however,  be  no  doubt  that  sufficient  work  has  been  done  to 
establish  the  probability  that  renal  cortical  lesions  generally  occur, 
though  with  a  considerable  range  of  variation. 

The  most  frequent  changes  found  are  as  follows  :  The  kidneys 
are  enlarged  and  less  firm  than  normal ;  the  cortices  are  swollen, 
anemic,  and  of  a  pale-gray  color ;  cloudy  swelling  and  granular 
changes  are  found  in  the  cells  of  the  tubules,  and  often  fatty  de- 
generation. In  a  small  number  of  cases  it  is  certain  that  the 
kidneys  may  not  recover  from  this  condition  after  labor,  but  may 
pass  into  a  permanent  true  parenchymatous  nephritis.  In  the 
majority  of  instances,  however,  there  is  every  reason  to  believe 
that  they  may  be  restored  to  their  normal  condition  in  a  short 
time.  Olshausen  has  described  an  interesting  case  in  which  the 
urine  contained  abundant  albumin,  casts,  and  blood-corpuscles  at 
the  time  of  labor,  eclamptic  phenomena  being  also  present.  The 
patient  died  five  days  after  delivery,  and  at  the  postmortem  ex- 
amination no  changes  whatever  were  found  in  the  kidneys. 

Of  extreme  interest  is  the  con.sideration  of  the  etiology  of  the 
albuminuria  and  renal  changes  above  described.     The  subject  is 


314  AFFECTIONS   OF   THE    URINARY  SYSTEM. 

an  extremely  difificult  one,  and  has  been  the  occasion  of  much 
speculation  and  much  polemic  writing.  Only  a  brief  reference  to 
the  most  important  views  is  here  possible. 

Coviprcssicvi  of  tlic  Ureters. — Halbertsma,  of  Utrecht,  from 
his  studies  of  eclampsia,  believes  that  increased  intra-abdominal 
pressure  due  to  the  pregnant  uterus  may.  by  interference  with  the 
functions  of  the  ureters,  lead  to  alterations  in  the  renal  structure. 
He  thinks  that  the  special  tendency  to  these  alterations  in  primi- 
parae — hydramnios,  multiple  gestation,  contracted  pelvis — in  all 
of  which  the  pressure  is  increased,  strengthens  his  view.  Ries, 
holding  somewhat  similar  views,  believes  that  in  some  cases  com- 
pression of  the  ureters  by  the  presenting  part  of  the  fetus  is  the 
most  important  factor.  These  views  have  not  been  accepted  by 
most  authorities.  Halbertsma's  statement  that  dilatation  of  the 
ureters  is  frequent  in  such  cases  has  not  been  corroborated.  Ols- 
hausen  found  dilatation  only  7  times  in  37  postmortems.  In 
Herzfeld's  8 1  autopsies  of  eclamptics  bilateral  dilatation  of  the 
ureters  was  found  in  18,  all  of  whom  were  primiparae.  (See 
chapter  on  "  Eclampsia.") 

For  my  own  part  I  believe  that  too  little  attention  has  been 
given  to  the  opinions  of  Halbertsma  and  Ries.  While  it  is  true 
that  the  anatomic  relationships  of  the  ureters  are  such  that  they 
are  generally  protected  from  the  pressure  of  the  pregnant  uterus 
or  its  contents  at  any  special  point,  the  possibility  of  an  abnormal 
pressure  over  a  considerable  extent  of  the  ureters  in  certain  cases 
cannot  be  denied.  Though  the  projecting  vertebral  bodies  are  the 
main  safeguard  from  pressure  on  the  ureters,  they  cannot  entirely 
protect  it.  My  frozen  sections  and  casts  of  pregnant  women  show 
that  the  enlarged  uterus  moulds  itself  accurately  along  the  spine 
and  on  each  side  of  it.  At  the  brim  this  moulding  is  particularly 
well  shown.  In  conditions  of  tense  abdominal  wall,  such  as  is 
found  in  young  or  old  primiparae,  or  of  abnormally  large  uterus, 
as  in  hydramnios  or  multiple  pregnancy,  it  is  very  evident  that  the 
general  pressure  on  the  uterus  must  be  increased.  In  the  late 
weeks  of  pregnancy,  as  is  well  known,  the  fetal  head  lies  in  the 
pelvic  cavity  in  primiparae,  and  if  the  pelvis  be  justo-minor  or 
funnel-shaped  in  type,  or  the  head  be  abnormally  ossified  or  en- 
larged, the  ureters  can  scarcely  escape  being  unduly  compressed 
against  the  pelvic  wall.  Even  though  in  these  various  conditions 
there  may  not  be  a  local  interference  with  the  flow  through  the 
ureters,  there  ma}'  be  produced  a  paresis  of  their  walls,  as  Halbertsma 
first  suggested,  leading  to  a  marked  weakening  of  their  peristaltic 
action. 

The  earlier  critics  of  this  worker  pointed  out  that  the  pressure 
theory  could  not  explain  the  cases  in  which  renal  disturbances 
developed  in  the  puerperium.  My  recent  studies  of  the  puerperal 
woman   by  means  of  frozen  sections  supply  a  very  evident  expla- 


CHANGES   IN    THE   KIDNEYS  DURING   PREGNANCY.      315 

nation.  I  have  shown  that  the  postpartum  uterus,  in  its  retracted 
and  contracted  condition,  fills  the  greater  part  of  the  normal  pelvic 
cavity  to  such  an  extent  as  to  form  a  ball  plug,  compressing  all 
extra-uterine  tissues  firmly  against  the  pelvic  wall,  interfering  con- 
siderably with  the  circulation  of  blood  through  them.  The  ureters 
share  in  this  compression.  This  condition  of  affairs  lasts  for  three 
or  four  days,  during  which  period  renal  disturbances  most  fre- 
quently occur.  The  postpartum  uterus  varies  somewhat  in  size, 
and,  therefore,  if  it  be  rather  larger  than  normal,  or  if  the  pelvis 
be  justo-minor  or  funnel-shaped  in  type,  greater  compression  is 
produced.  Ries,  Halbertsma,  and  others  have  shown  that  pelvic 
inflammatory  exudates  may  cause  compression  of  the  ureters,  and 
consequent  renal  disturbance  in  the  puerperium.  It  is  interesting 
to  note  in  this  connection  that  large  fibroid  and  ovarian  tumors, 
especially  the  former,  are  not  infrequently  associated  with  changes 
in  the  urine,  kidneys,  and  ureters  similar  to  those  found  in  preg- 
nancy ;  and  in  some  cases  the  renal  function  may  be  very  markedly 
altered. 

Finally  it  is  interesting  to  note  certain  experiments  on  animals. 
Aufrecht  ligated  a  ureter  in  a  dog  and  killed  the  animal  three 
days  later.  The  corresponding  kidney  was  much  swollen,  its 
pelvis,  along  with  the  upper  part  of  the  ureter,  distended.  The 
cortical  tubules  of  the  kidney  were  damaged,  being  somewhat 
dilated  and  containing  abundant  hyaUne  or  fibrinous  casts,  their 
epithelium  showing  granular  and  fatty  changes. 

Apart  from  compression  of  the  uterus,  it  may  be  that  the  kid- 
neys themselves  are  so  affected  by  certain  degrees  of  increased 
intra-abdominal  pressure  as  to  undergo  degeneration  ;  or  it  may 
be  that  in  the  same  manner  the  renal  circulation  is  interfered  with. 
Compression  of  the  renal  arteries  or  interference  with  the  flow  of 
blood  in  the  veins  is  sufficient  to  induce  albuminuria  and  degen- 
eration in  the  kidneys  if  continued  long  enough. 

Influence  of  the  Products  of  Metabolism. — Virchow,  in  1848, 
stated  that  disturbances  in  the  kidneys  during  pregnancy  were 
mainly  due  to  the  influence  of  altered  body  metabolism,  and 
he  pointed  out  the  frequency  with  which  the  renal  changes  are 
accompanied  by  corresponding  conditions  in  the  liver.  During 
the  past  fifty  years  different  theories  have  been  advanced  to  explain 
the  nature  of  the  alterations  induced  by  the  metabolic  processes 
in  pregnancy.  At  the  present  time  the  majority  of  authors  holds 
to  this  theory  in  a  general  way,  though  there  is  very  great  diver- 
gence of  opinion  as  to  its  actual  application. 

In  pregnancy  the  increase  in  maternal  metabolic  activity  is 
evident.  This  means  a  greater  quantity  of  excrementitious  matter 
to  be  eliminated.  As  the  ovum  develops  fetal  metabolism  be- 
comes a  more  and  more  important  factor.  Fetal  waste  products 
almost  entirely  enter  the  maternal  blood  by  transmission  through 


3l6  AFFECTIONS   OF  THE    URINARY  SYSTEM. 

the  walls  of  the  villi  from  the  fetal  circulation.  An  extra  burden 
is,  therefore,  thrown  upon  the  maternal  kidneys,  and  if  they  cannot 
respond  to  the  increased  demand  on  their  activity  they  are  apt  to 
suffer.  The  waste  products  may  exert  a  direct  poisonous  action 
on  the  cells  of  the  tubules,  or  indirectly  through  their  influence 
on  the  arteries  in  the  kidneys,  constricting  them  and  thereby  in- 
terfering with  the  nutrition  of  the  tubules.  The  changes  are 
believed  to  be  similar  to  those  found  in  such  conditions  as  ptomain- 
poisoning  and  acute  yellow  atrophy,  where  the  destruction  of  the 
kidney  tissue  may  be  very  rapid. 

The  influence  of  the  skin,  lungs,  liver,  and  intestines  aids  in 
getting  rid  of  the  waste  products  of  metabolism,  and  it  is  evident 
that  interference  with  their  functions  will  throw  greater  burdens 
on  the  kidneys.  It  is  in  pregnancy  especially  that  these  functions 
are  apt  to  be  interfered  \\ith  ;  in  most  civilized  countries  a  large 
percentage  of  pregnant  women  are  prejudiced  against  free  cleansing 
of  the  skin  of  the  body.  The  production  of  albuminuria  in  a 
healthy  dog  by  varnishing  its  skin  is  a  well-known  experiment. 
Then  the  tendency  to  irregularit}'  in  the  digestive  tract  and  to 
constipation  in  pregnant  women  is  a  very  common  one.  Clin- 
ically it  is  veiy  easy  in  the  albuminuria  of  pregnancy  to  prove 
that  promotion  of  free  action  of  the  skin  or  bowels,  or  of  both 
combined,  ma}-  rapidly  lead  to  a  diminution  in  the  quantity  of 
albumin  in  the  urine. 

With  regard  to  the  influence  of  the  fetal  waste  products,  it  has 
been  noted  in  cases  of  albuminuria  that  death  of  the  fetus  may 
lead  to  a  rapid  diminution  or  disappearance  of  the  albuminuria, 
and  this  is  believed  to  be  due  to  the  cessation  in  the  transmission 
of  the  waste  products  from  the  fetus  to  the  maternal  blood. 
There  is  much  speculation  as  to  the  nature  of  the  waste  products 
that  exert  the  destructive  influence.  Various  subjects  are  men- 
tioned— /.  r.,  leukomains  and  ptomains  formed  in  the  bowel  and 
reabsorbed  when  the  bowel  action  is  faulty;  also  kreatin,  inor- 
ganic salts  of  potash,  various  alkaloidal  products  of  digestion, 
etc.  The  extent  to  which  the  kidneys  may  be  affected  depends, 
therefore,  on  a  variety  of  factors.  In  the  majority  of  cases  in 
which  they  are  affected  no  permanent  damage  results,  nor  do 
serious  comphcations  arise.  In  a  certain  number  of  cases  serious 
renal  disease  may  be  induced,  and  in  a  con.siderable  number  of 
cases,  where  the  disproportion  between  circulating  poisonous 
waste  products  and  rectal  excretory  action  becomes  too  great,  the 
serious  phenomena  known  as  eclampsia  supervene,  the  woman's 
life  being  greatly  endangered. 

As  might  be  expected,  a  number  of  workers  have  advanced 
the  view  that  the  main  factor  in  producing  the  toxemia  of  preg- 
nancy is  microbic  infection.  Some  have  found  germs  in  the 
blood,  some  in  the  kidneys,  others  in  the  placenta ;  in  some  cases 


NEPHRITIS.  3  1 7 

cultures  injected  into  animals  have  produced  general  toxemia  and 
changes  in  the  kidneys  resembling  those  found  in  the  altered 
kidney  of  pregnancy.  Other  workers  have  obtained  negative 
results. 

While  it  is  impossible  at  the  present  time  to  postulate  any 
well-ascertained  results  regarding  the  relationship  of  micro-organ- 
isms to  the  toxemia  of  pregnancy,  in  view  of  such  experiments 
as  those  of  Doleris  and  Poney,  Blanc,  Favre,  Gerdes,  and  others, 
and  in  the  light  of  Adami's  work  on  subinfection,  it  cannot  be 
denied  that  in  some  cases  of  pregnancy  toxemia  the  important 
agent  may  be  some  form  of  microbe,  and  that  in  their  effort  to 
destroy  and  remove  the  organisms  the  kidneys  may  be  so  affected 
as  to  undergo  the  pathologic  changes  to  which  I  have  already 
referred,  with  consequent  accompanying  alterations  in  the  urinary 
secretion. 

Veit  has  recently  suggested  as  a  cause  of  albuminuria  in  preg- 
nancy the  deportation  from  the  placenta  of  peripheral  portions  of 
the  chorion,  leading  to  the  formation  of  a  toxic  "  lysin." 

Finally,  after  reviewing  the  most  important  theories  advanced 
by  those  who  have  worked  in  this  difficult  sphere,  it  must  be  ad- 
mitted that  much  is  to  be  said  in  favor  of  each.  Indeed,  it  is 
highly  probable  that  something  of  the  truth  is  contained  in  all  of 
them,  that  in  most  cases  no  single  factor  is  causal,  but  rather  a 
combination  of  various  factors,  these  varying  greatly  in  different 
instances.  The  most  important  of  these  is  undoubtedly  the  toxic 
element.  Only  from  such  a  standpoint  is  it  possible  to  group 
into  an  intelligible  synthesis  the  heterogeneous  clinical  phenomena 
and  physical  changes  found  in  the  abnormal  condition  of  preg- 
nancy under  consideration. 

Recently  an  attempt  has  been  made  to  explain  albuminuria  and 
eclampsia  by  faulty  action  of  the  thyroid  gland.  (See  chapter  on 
"  Eclampsia.")  Lange  has  stated  that  albuminuria  is  common 
when  the  normal  thyroid  hypertrophy  is  wanting. 

Albuminuria  due  to  catarrhal  condition  of  the  bladder,  ureters, 
or  pelvis  of  the  kidney  is  occasionally  found  in  pregnancy. 

Nephritis. — Where  true  nephritis  exists  before  or  begins 
during  pregnancy  the  disease,  as  a  rule,  is  more  serious  than  in 
the  non-pregnant  state  and  the  prognosis  is  unfavorable.  In  the 
case  of  chronic  nephritis  an  acute  exacerbation  is  usually  induced. 
The  patient  may  die  from  kidney  failure,  and  uremia  is  very  apt 
to  occur.  Only  in  a  small  percentage  of  cases  are  the  phenomena 
of  eclampsia  noted,  as  has  been  pointed  out  by  Fehhng  and 
Leyfert. 

As  regards  the  influence  on  the  course  of  pregnancy,  the 
tendency  to  premature  emptying  of  the  uterus  is  to  be  particularly 
noted.  According  to  P.  Miiller  it  occurs  in  more  than  40  per 
cent,  of  cases  ;  it  is  attributed  mainly  to  the  occurrence  of  hemor- 


31 8  AFFECTIONS   OF   THE    URINARY  SYSTEM. 

rhages  into  the  placenta  or  to  infarct  formation,  causing  destruction 
of  portions  of  the  chorionic  villi,  and  to  the  accumulation  of  toxic 
material  in  the  system.  The  fetal  mortality  is  very  high.  Hof- 
meier  noted  that  the  fetus  died  in  20  out  of  23  cases  of  nephritis. 
Braun  has  estimated  the  mortality  at  80  per  cent.  In  iio  cases 
of  albuminuria  without  eclampsia  reported  by  Charles,  8  mothers 
and  20  children  died;  there  were  61  premature  labors  and  8  post- 
partum hemorrhages. 

Treatment. — The  treatment  of  a  pregnant  w^oman  with  symp- 
toms pointing  to  disturbed  renal  functions  is  to  be  carried  out  on 
the  lines  followed  in  the  non-pregnant  state.  The  strictest  watch- 
fulness on  the  part  of  the  physician  is  necessary.  With  regard 
to  the  question  of  allowing  the  pregnancy  to  continue  it  is  difficult 
to  decide.  There  are,  however,  certain  indications  that  point  im- 
peratively to  the  induction  of  premature  delivery,  in  the  interests 
of  the  mother — viz.,  visual  disturbances,  continued  headache, 
pulmonary  or  other  marked  edema,  marked  cardiac  disturbance, 
frequent  nose-bleedings,  continued  increase  in  casts  and  albumin 
in  the  urine,  and  uremia.  In  a  number  of  cases  the  woman  may 
respond  to  treatment  so  satisfactorily  as  to  go  to  full  term  and  be 
delivered  of  a  healthy  child. 

Pyelonephritis. — This  condition  is  occasionally  found  and 
may  easily  be  mistaken  for  cystitis.  The  disease  usually  develops 
in  the  second  half  of  pregnancy,  the  infecting  organism  being  most 
frequently  the  colon  bacillus,  though  the  route  by  which  it  gains 
entrance  is  not  ah\a}-s  certain.  Infection  is  favored  by  increased 
pressure  on  the  ureters,  cystitis,  constipation,  cold,  fatigue,  and 
overwork.  The  onset  of  the  disease  is  usually  very  sudden,  being 
marked  by  pains  in  the  side.  In  almost  all  cases  the  right  kidney 
is  affected.  Sometimes  the  corresponding  ureter  may  be  infected  ; 
the  bladder  may  also  be  involved.  After  labor  the  disease  tends 
to  disappear  steadily.  If  the  kidney  becomes  distended  with  pus, 
it  is  best  to  empty  the  uterus  and  to  treat  the  diseased  organ 
surgically  somewhat  later.  Surgical  interference  with  the  kidney 
during  pregnancy  is  not  advisable.  The  prognosis  is  fairly  favor- 
able both  for  the  mother  and  child.  Premature  emptying  of  the 
uterus  rarely  occurs. 

In  pregnancy  the  patient  must  be  carefully  watched.  She 
should  live  on  a  milk  diet  and  should  take  urotropin. 

Pregnancy  after  Nephrectomy. — It  is  interesting  to  note 
that  in  women  who  have  become  pregnant  after  the  loss  of  a 
kidney  by  operation  no  special  tendency  to  eclampsia  has  been 
noted.  Cases  have  been  observed  by  Schramm,  Twynam, 
Fritsch,  Israel,  myself,  and  others.  In  a  number  of  these  preg- 
nancy and  labor  have  proceeded  normally,  no  changes  even  having 
been  noted  in  the  urine ;  nor  has  the  fetus  been  abnormal. 


AFFECTIONS   OF   THE   SKIN.  319 

CHAPTER    X. 

AFFECTIONS  OF  THE  SKIN. 

Herpes. — From  the  supposed  frequency  of  this  condition  in 
pregnancy  it  has  been  termed  Jicrpes  gcstatioiiis.  It  is  an  eruptive 
condition  consisting  of  erythema,  vesicles,  and  bullae.  It  may 
appear  early  in  pregnancy  and  may  continue  throughout  its  dura- 
tion.    Frequently  it  is  associated  with  neurotic  manifestations. 

Impetigo  herpetiformis  is  a  pustular  development,  occur- 
ring especially  in  the  parts  subjected  to  moisture — /.  c,  armpits, 
groin,  navel,  and  under  surface  of  the  breasts.  It  is  accompanied 
with  systemic  disturbances — /.  c,  fever,  rigors,  weakness,  vomit- 
ing, and  sometimes  delirium ;  it  may  end  fatally.  Acne,  eczema, 
and  urticaria  sometimes  develop  during  gestation.  Occasionally 
these  conditions  improve  when  a  woman  becomes  pregnant. 

I/OOSening  of  the  finger  nails  sometimes  occurs,  and  is 
associated  with  considerable  pain.  It  may  recur  in  succeeding 
pregnancies. 

Pruritus. — This  condition  may  be  found  in  any  period  of  ges- 
tation, but  is  probably  most  common  in  the  early  months.  It  is 
most  frequently  localized  in  the  vulvar  region,  but  it  may  be  more 
or  less  widespread.  Itching  may  be  due  to  any  of  the  conditions 
that  produce  it  in  the  non-pregnant  state,  but  in  pregnancy  there 
may  often  be  no  evident  cause,  and  it  is  generally  regarded  as  a 
neurosis. 

Pigmentation. — The  ordinary  color  changes  have  already 
been  noted.  Sometimes  there  is  excessive  pigmentation  deposited 
in  patches.  These  tend  to  disappear  after  pregnancy,  but  generally 
some  traces  remain. 


CHAPTER    XI. 

AFFECTIONS  OF  THE  REPRODUCTIVE  SYSTEM. 

Pruritus  Vulvae. — Itching  may  be  troublesome  in  the  region 
of  the  labia,  perineum,  anus,  or  groin.  Sometimes  the  affected 
area  may  extend  widely  from  these  parts.  The  disturbance  may 
be  caused  by  excessive  leukorrhea,  marked  congestion,  and  irri- 
tation of  the  parts  by  exercise  ;  sometimes  diabetes  is  a  cause. 
Local  skin  disease  may  be  present.  Hemorrhoids  or  worms  in 
the  rectum  may  lead  to  itching.  In  some  cases  no  local  cause  can 
be  found  and  the  condition  is  then  regarded  as  a  neurosis.     The 


320  AFFECTIONS    OF   THE   REPRODUCTIVE   SYSTEM. 

woman  is  sometimes  so  distressed  that  she  becomes  sleepless, 
worn,  and  excitable,  and  may  completely  lose  control  of  herself. 
She  may  scratch  herself  so  severely  as  to  cause  bleeding ;  or  she 
may  infect  the  skin,  setting  up  inflammatory  changes. 

Treatment  is  often  very  unsatisfactory.  Any  local  cause  should 
be  corrected  so  far  as  possible.  External  inflamed  conditions  are 
best  relieved  by  a  series  of  boric  starch  poultices.  When  the 
vagina  or  cervix  is  affected,  warm  astringent  antiseptic  douches 
may  be  tried — i.  e.,  formalin  (TTXxvj-Oj).  Sometimes  the  itching 
is  relieved  by  hot  or  cold  fomentations.  Ointments  of  menthol, 
cocain,  bismuth,  or  carbolic  acid  are  also  used.  Silver  nitrate 
solution  (2  per  cent.),  vinegar,  and  tobacco  infusion  have  also  been 
recommended.  When  the  affected  area  is  small  and  the  itching 
intense,  no  relief  being  obtained  by  the  ordinaiy  remedies,  the 
question  of  excising  the  itching  portion  of  skin  may  be  considered. 
When  the  health  of  the  patient  suffers  markedly  it  may  be  nec- 
essary to  empty  the  uterus. 

Varices  may  cause  considerable  swelling  of  the  vaginal  wall 
or  vulva.  Rupture  may  be  caused  by  a  strain  or  contact  with  a 
hard  body  and  dangerous  or  fatal  bleeding  result. 

Haematoma  vulvae  is  generally  caused  by  a  kick  or  fall, 
leading  to  the  subcutaneous  rupture  of  a  vessel,  which  may  or 
may  not  be  varicose.  When  the  swelling  is  large  the  skin  be- 
comes much  thinned  over  it  and  infection  may  occur,  leading  to 
suppuration.  Small  blood-extravasations  may  be  absorbed  if  the 
patient  be  kept  at  rest  and  cold  be  applied  to  the  affected  area. 
Large  ones  should  be  incised,  the  clot  removed,  and  the  cavity 
stuffed  with  antiseptic  gauze,  being  allowed  to  shrink  gradually. 

Vulvar  Cyst. — A  small  Bartholinian  cyst  need  not  be  inter- 
fered with  until  after  labor.  A  large  or  growing  one  that  may  be 
so  large  as  to  interfere  with  the  birth  of  the  child  should  be  re- 
moved if  there  is  sufficient  time  to  get  healthy  closure  of  the 
wound  before  labor.  Otherwise  the  cyst  may  be  evacuated  by 
puncture  at  the  time  of  delivery,  the  wound  being  kept  clean ;  at 
a  later  period  the  cyst  may  be  removed. 

Inflammations  of  the  i^xternal  Genitals. — All  infective 
conditions,  whether  venereal  or  not,  require  to  be  treated  with 
great  thoroughness  during  pregnancy,  in  order  that  the  parts  may 
be  in  a  healthy  state  at  the  time  of  labor.  Venereal  vegetations 
may  require  to  be  cut  away. 

Vulvar  Abscess. — This  is  a  serious  complication  if  it  occur 
near  the  end  of  pregnancy,  since  it  may  lead  to  infection  in  labor. 
It  should  be  opened  and  thoroughly  cauterized  and  packed  with 
moist  antiseptic  gauze  until  all  the  infective  organisms  are  de- 
stroyed and  healthy  heaUng  is  in  progress. 

Vulvar  Tumors. — If  large  enough  to  interfere  with  labor, 
these  may  be  removed  in  pregnancy  or  at  the  time  of  labor. 


EDEMA — HYPERTROPHY  OE   THE    VAGTNAL    WALL.      32 1 

i^dema. — Edema  of  the  vulva  may  be  found  on  one  or  both 
sides.  It  may  be  due  to  heart  or  kidney  disease,  but  is  also  found 
when  these  are  not  present — /.  e.,  when  the  circulation  is  interfered 
with  by  excessive  intra-abdominal  pressure.  Thus,  it  may  occur 
with  hydramnios,  twin  pregnancy,  pendulous  belly,  pregnancy 
complicated  with  a  tumor,  etc.  It  may  also  be  associated  with 
local  inflammatory  conditions.  If  there  be  marked  edema  at  the 
time  of  labor  the  swelling  may  cause  serious  delay ;  it  may  be 
increased  by  the  labor,  and  as  a  result  of  the  pressure  may  be  so 
damaged   that  infection   may  cause  inflammation   of  the   tissues, 


Fig.   135. — Prolapsed   lower  portion  of  anterior  vaginal  wall,  deeply  congested  and 

resembling  a  polypus.     The  patient  was  a  multipara  near  the  end  of  pregnancy. 


abscess  formation,  or  even  gangrene.  In  treating  the  condition  it 
is  important  to  attend  to  the  chief  cause.  In  all  cases  the  activity 
of  the  skin  and  kidneys  should  be  promoted.  Rest  in  bed  is  of 
great  importance,  elevation  of  the  lower  end  of  the  bed  being 


advisable  unless   distressing  to   the   patient, 
may    be    applied    to    the    vulva.      When    all 
swelling  should   be  punctured    under  strict 
in   r)rder  to  remove  an  obstacle  to  delivery. 
Hypertrophy  of  the  Vaginal  Wall.- 
swellings  form  during  pregnancy  in  the   regi 

21 


Hot  fomentations 

measures    fail    the 

aseptic   precautions 

-Occasionally  local 
on  of  the  introitus 


322 


AFFECTIONS   OF  THE   REPRODUCTIVE   SYSTEM. 


vaginae.  They  may  develop  in  the  remains  of  the  hymen  or 
in  the  vaginal  wall,  especially  anteriorly.  The  tissues  are  mark- 
edly discolored  from  intense  congestion.  In  some  instances 
the  swellings  resemble  polypi.  They  disappear  after  labor.  Leu- 
korrhea  may  be  due  to  vulvar,  vaginal,  or  cervical  inflamma- 
tion. In  the  early  months  it  may  also  be  due  to  changes  in  the 
endometrium,  above  the  os  internum.  It  may  be  very  annoying 
to  the  woman.  Formalin  douches  (TTLxxv-Oj)  are  of  value  in 
diminishing  the  leukorrhea  when  it  is  cervical  or  vaginal  in  origin. 
Sometimes  in  addition  it  is  advisable  to  apply  iodized  phenol  or  a 


Fig.  136. — Elephantiasis  of  the  labia  (one-fourth  life  size). 

30  per  cent,  solution   of  carbolic  acid  in  glycerin  to  the  affected 
area. 

Hydrorrhoea  Gravidarum. — This  term  is  applied  to  a  pro- 
fuse thin  discharge  that  may  escape  from  the  genital  canal  of  a 
pregnant  woman,  continuously  or  intermittently.  It  varies  in 
appearance,  and  may  be  pale,  yellow,  greenish,  or  sanious.  In 
early  pregnancy  it  is  most  frequently  due  to  endometritis,  the 
fluid  passing  into  the  space  between  the  decidua  vera  and  reflexa 
and  thence  escaping  into  the  vagina  through  the  cervical  canal. 
A  catarrhal  condition  of  the  cervix  may  also  cause  a  considerable 
discharge.  In  hydatidiform  degeneration  of  the  chorion  there 
may  be  a  marked  outflow  of  clear  fluid,  sometimes  blood-stained. 
It  is  also  probably  sometimes  due  to  the  escape  of  liquor  amnii 
through  a  small  opening  in  the  membranes.  Malignant  disease 
of  the  cervix  may  also  lead  to  a  free  discharge.  Grimodie  believes 
that  the  condition   may  be  produced  in  cases  of  valvular  heart 


CHRONIC  ENDOMETRiriS.  323 

disease  in  the  mother.  In  some  cases  of  hemorrhage  under  the 
placenta  in  pregnancy  a  clot  may  form,  and  from  it  serum,  clear 
or  slightly  blood-stained,  may  escape  downward  under  the  mem- 
branes and  pass  into  the  vagina.  The  author  had  under  observa- 
tion a  patient  in  whom  such  a  discharge  continued  nearly  two 
weeks  before  labor  began.  In  all  cases  the  woman  should  be 
kept  at  rest  and  the  most  thorough  physical  examination  made. 

Hemorrhage  from  the  Genital  Tract. — Bleeding  during 
pregnancy  may  be  due  to  various  causes — i.  e.,  rupture  of  the 
decidua  reflexa  when  the  placenta  is  attached  to  it,  separation  of 
the  placenta  when  it  is  entirely  serotinal,  threatened  abortion 
due  to  various  causes,  simple  and  malignant  growths  of  the 
uterus,  menstruation  occurring  in  the  early  months,  and  inflamma- 
tion in  the  decidua.  It  may  also  take  place  from  the  uterus  when 
the  gestation  is  ectopic. ,  It  may  also  be  due  to  new  growths  of 
the  vagina  and  vulva  or  to  injuries  of  these  parts. 

Inflammation  in  the  Uterus. — Acute  metritis  is  very  rare 
in  pregnancy.  It  may  occur  in  some  of  the  infectious  diseases — 
/.  c,  cholera.  It  may  follow  septic  infection — /.  e.,  in  attempted 
abortion ;  sometimes  this  takes  place  when  the  retroflexed  gravid 
uterus  becomes  impacted  in  the  pelvis.  The  wall  becomes  soft 
and  may  rupture.  Chronic  metritis  is  common,  having  existed 
before  pregnancy.  It  frequently  renders  the  diagnosis  of  gesta- 
tion difficult  in  the  early  months,  because  the  uterine  wall  is  larger 
and  harder  than  normal.  In  such  cases  the  pregnancy  may  easily 
be  overlooked.  Careful  and  repeated  examinations  during  the 
course  of  several  weeks  may  be  necessary  to  establish  the  diag- 
nosis. Chronic  endocervicitis  may  cause  a  profuse  discharge  that 
may  be  very  troublesome.  Catarrhal  patches  on  the  vaginal  por- 
tion of  the  cervix  may  be  treated  by  the  application  of  iodized 
phenol  or  nitrate  of  silver  and  warm  astringent  antiseptic  douches. 
All  such  measures  must  be  carefully  carried  out  on  account  of  the 
risk  of  starting  an  abortion.  This  risk  should  always  be  explained 
to  the  patient. 

Chronic  i^ndometritis. — This  condition  is  usually  a  con- 
tinuation of  an  inflammation  existing  before  pregnancy.  It  may 
affect  all  parts  of  the  decidua  in  varying  combinations.  It  occurs 
in  the  following  forms  : 

1.  A  general  diffuse  thickening,  the  changes  affecting  both 
glands  and  interglandular  tissue,  changes  in  one  or  other  of  these 
tissues  being  usually  predominant. 

2.  Localized  changes.  The  inflammatory  changes  may  be 
limited  to  certain  areas  or  may  be  much  more  intense  in  some 
parts  than  in  others.  The  decidua  may  be  thickened  so  as  to 
form  elevations  that  may  sometimes  assume  a  polypoidal  shape  ; 
these  consist  largely  of  interglandular  tissue,  the  cells  being  of 
the  decidual  type. 


324  AFFECTIONS   OF   THE   REPRODUCTIVE   SYSTEM. 

Hemorrhages  may  occur  in  connection  with  chronic  inflam- 
matory changes  in  the  decidua,  and  may  affect  both  the  decidua 
and  the  fetal  tissues.  Thrombosis,  and  thickening  of  the  walls 
of  vessels,  may  be  found  more  marked  and  earlier  in  pregnancy 
than  in  normal  cases.  Retention  cysts  may  develop  from  obliter- 
ated glands.  The  chorionic  structures  attached  to  the  decidua 
may  also  become  affected  and  both  tissues  may  become  very 
firmly  united.  In  the  early  months  of  pregnancy  the  woman 
usually  complains  of  a  thin  mucous,  mucopurulent,  or  blood- 
stained discharge,  which  varies  in  quantity  in  different  cases.  It 
is  frequently  aggravated  at  the  times  corresponding  to  the  men- 
strual periods.  There  is  a  tendency  to  abortion.  Very  little  can 
be  done  in  treating  these  conditions  during  pregnancy.  After- 
w^ard  careful  measures  should  be  employed  before  another  gesta- 
tion takes  place. 

Fibromyoma  Uteri. — Uterine  fibroids  are  frequently  asso- 
ciated with  sterilit}'.  Chaipentier's  statistics  show  that  in  1554 
cases  there  w^as  sterility  in  476.  Hofmeier  states  that  the  per- 
centage is  not  greater  than  in  women  with  a  normal  uterus.  The 
exact  relationship  between  this  disease  and  conception  is  unknown, 
since  pregnancy  or  sterility  may  be  found  with  all  varieties  of 
fibroids. 

In  some  instances  pregnancy  and  labor  may  run  a  normal 
course.  This  is  especially  the  case  when  the  fibroids  are  small 
or  few,  when  they  are  subperitoneal  and  placed  high  on  the 
uterine  body,  and  when  they  do  not  grow^  rapidly.  But  in  many 
cases  compHcations  more  or  less  serious  are  produced. 

Pressure  symptoms  may  be  present  in  the  early  months  when 
the  tumor  or  tumors  lie  within  the  true  pelvis,  especially  if  they 
are  intraligamentous.  Sometimes  at  this  period  a  pedunculated 
subperitoneal  growth  may  lie  deeply  in  the  pelvis,  and  in  such 
cases  the  mass  may  become  impacted.  Occasionally  prolapsus 
or  retroversion  of  the  uterus  may  be  caused  in  the  early  months. 
In  advanced  gestation  pressure  symptoms  may  be  caused  by 
multiple  or  large  tumors.  Intra-uterine  hemorrhages  may  be 
caused,  especially  when  submucous  tumors  are  present.  Placenta 
prjevia  is  found  in  a  larger  percentage  of  cases  than  where  the 
uterus  is  normal.  Rarely,  spontaneous  thinning  and  rupture  of 
the  uterus  may  take  place.  "Fibroids  are  frequently  a  cause  of 
premature  emptying  of  the  uterus,  though  Hofmeier  believes  that 
this  is  not  so  common  as  is  generally  believed.  He  states  that  in 
796  cases  this  complication  took  place  only  in  6.9  per  cent. 
Nauss,  however,  describes  it  as  occurring  47  times  in   241  cases. 

In  a  number  of  instances  in  advanced  pregnancy  death  of  the 
fetus  has  not  been  followed  by  its  immediate  expulsion,  even 
though  the  liquor  amnii  has  escaped ;  decomposition  of  the 
uterine  contents  is  likely  to  follow  retention.     Pujol  finds  that  in 


FIBROMYOMA    UTERI.  325 

100  cases,  53.82  per  cent,  presented  by  the  head,  27.18  per  cent, 
by  the  breech,  and  19  per  cent,  were  transverse.  Malpresenta- 
tions  and  malpositions  are  frequent.  Labor  pains  may  be  weak, 
irregular,  and  ineffectual.  Of  great  importance  are  the  effects 
produced  by  large  fibroids  (which  may  also  be  present  when  they 
are  not  complicated  by  pregnancy) — viz.,  degeneration  of  the 
cardiac  muscle  and  of  the  renal  and  hepatic  epithelium.  The 
heart  may  also  be  dilated  more  than  in  normal  pregnancy. 

The  symptoms  vary  considerably.  In  some  cases  the  tumors 
cause  no  disturbance.  When  pressure  is  present  there  may  be 
pains  in  the  abdomen  or  pelvis,  varicose  veins,  edema,  weakness 
or  pain  in  one  or  both  lower  extremities,  edema  or  varicose  veins 
in  the  vulva,  and  hemorrhoids.  There  may  be  various  disturb- 
ances of  the  bowel  and  bladder.  There  may  be  diminution  of  the 
quantity  of  urine  and  of  its  solids  ;  albuminuria  and  casts  may 
be  present.  There  may  be  symptoms  resulting  from  cardiac 
weakness.  Frequently  the  patient's  discomfort  is  aggravated  on 
exertion.  The  rhythmic  uterine  contractions,  which  normally  are 
painless,  are  sometimes  excessive  and  painful.  Blood  may  escape 
from  the  uterus  at  times  even  though  abortion  be  not  induced. 

The  effect  of  pregnancy  on  fibroids  varies.  They  tend  to  grow, 
the  rate  varying  greatly  ;  those  that  are interstitialincreasing  most 
rapidly.  The  consistence  may  change  considerably ;  sometimes 
a  tumor  may  become  much  softer.  Occasionally  there  may  be  a 
complete  breaking  down  of  the  central  portion.  Tarnier  and 
Budin  state  that  fibroids  may  become  alternately  harder  and  softer, 
like  the  uterine  wall  in  pregnancy  ;  it  is  uncertain  whether  this  is 
due  to  activity  of  the  muscle  fibers  in  the  tumor  or  to  that  of 
the  surrounding  uterine  muscle,  the  tumor  remaining  inert.  It  is 
doubtful  if  this  muscular  activity  is  found  in  any  but  soft  myomata, 
and  in  more  than  a  very  slight  extent. 

The  diagnosis  of  fibroids  and  pregnancy  is  beset  with  diffi- 
culties. In  some  cases  the  fibroids  may  be  regarded  as  parts  of 
the  fetus,  or  they  may  be  missed  when  situated  on  the  posterior 
part  of  the  uterus.  Frequently  the  pregnancy  may  be  entirely 
overlooked,  or  diagnosed  as  a  cystic  swelling  in  connection  with 
the  tumors.  Sometimes  pregnancy  with  fibroids  is  regarded  as 
multiple  pregnancy.  In  the  early  months  a  single  fibroid  with 
pregnancy  may  resemble  an  enlarged  metritic  uterus.  Very  fre- 
quently a  fibroid  may  simulate  the  uterine  body  in  shape,  the 
pregnancy  being  considered  as  ectopic ;  or  sometimes  the  latter 
may  be  diagnosed  as  an  ovarian  cyst.  Occasionally  there  may  be 
a  simulation  of  a  bicornute  uterus  with  pregnancy  in  one  horn. 
Sometimes  a  fibroid  may  be  mistaken  for  a  tubal  or  ovarian 
swelling.  Examination  must  be  carried  out  repeatedly  and  with 
great  care,  anesthesia  often  being  necessary.  In  some  cases  an 
absolute  diagnosis  cannot  be  established. 


326  AFFECTIONS   OF   THE   REPRODUCTIVE   SYSTEM. 

Treatment. — When  there  are  one  or  more  small  tumors,  causing 
no  symptoms,  the  case  may  be  allowed  to  proceed  to  full  time, 
frequent  examinations  being  made  to  determine  the  relationships 
of  the  fibroids  and  their  rate  of  growth.  If  in  the  early  months 
a  subperitoneal  tumor  lying  in  the  pelvis  is  in  danger  of  becoming 
impacted,  an  effort  should  be  made  to  raise  it  above  the  brim  by 
placing  the  patient  in  the  genupectoral  position,  the  lower  bowel 
and  bladder  ha\ing  been  emptied,  and  digital  pressure  being  made 
through  the  vagina  and  rectum.  If  this  is  unsuccessful  after  two 
or  three  attempts  have  been  made,  either  abortion  must  be  in- 
duced or  an  abdominal  section  must  be  performed  in  order  that 
the  tumor  may  be  removed.  After  the  latter  operation  there  is  a 
considerable  chance  that  the  pregnancy  may  continue.  When  a 
large  interstitial  tumor  is  situated  in  the  fundus  of  the  uterus  it  is 
possible  that  the  pregnancy  may  continue  without  danger.  Such 
growths  ma}^  sometimes  be  safely  removed  by  myomectomy  with- 
out interruption  of  the  pregnancy.  This  operation  may,  however, 
lead  to  abortion.  Stavely,  in  1894,  published  an  account  of  33 
cases  of  myomectomy  during  pregnane}'.  The  maternal  mortality 
was  24.25  per  cent. ;  in  the  cases  operated  upon  between  1885  and 
1889  it  was  16.66  per  cent. ;  in  those  operated  upon  between  1889 
and  1894  it  was  11.75  per  cent.  In  30.30  per  cent,  abortion 
occuiTed.  Twenty  of  the  cases  went  to  full  term.  Duncan  Emmet 
has  reported  44  cases  as  occurring  between  1890  and  1900,  with 
a  maternal  mortality  of  9  per  cent.  The  operation  of  myomec- 
tomy must  have  a  very  limited  sphere  in  pregnancy.  It  is  un- 
necessary^ to  remove  very  small  tumors.  Those  which  are  large 
and  interstitial  should  not  be  removed  in  this  way  because  of  the 
risk  of  rupturing  the  stitched  area  in  case  abortion  should  occur, 
or  even  if  a  full-time  labor  should  take  place.  Practically  it  need 
be  carried  out  only  in  the  case  of  subperitoneal  fibroids  that  are 
situated  low  enough  to  be  a  source  of  danger  at  full  time,  or 
which  have  such  long  pedicles  that  they  are  apt  to  fall  into  the 
pelvis. 

If  an  interstitial  fibroid  be  situated  near  the  cervix  there  is  risk 
of  impaction  in  the  early  months  and  of  obstruction  in  the  case  of 
labor  in  the  late  months.  Abortion  should,  therefore,  be  induced 
early  if  it  can  be  carried  out  safely  and  without  much  difficulty. 
Otherwise  it  may  be  advisable  to  perform  hysterectomy  by  the 
vaginal  or  abdominal  route.  Removal  by  myomectomy  should 
not  be  attempted  in  such  cases,  at  least  until  the  uterus  has  been 
emptied.  Where  there  are  several  tumors  large  in  size,  rapid  in 
growth,  or  causing  pressure  symptoms,  abdominal  hysterectomy 
should  be  performed.  In  a  number  of  cases  in  advanced  preg- 
nancy a  viable  fetus  may  be  removed  from  the  uterus  before  the 
latter  is  excised.  Sometimes  the  parents  desire  to  prolong  gesta- 
tion as  far  as  possible  in  order  to  ensure  viability.     They  should 


CARCINOMA    UTERI.  327 

always  be  warned  that  delay  may  increase  the  risk  to  the  mother 
if  the  tumors  cause  much  pressure  or  if  the  heart  and  kidneys  are 
not  acting  satisfactorily. 

In  opening  the  uterus  for  the  removal  of  the  fetus  it  may  be 
necessary  to  make  an  irregular  incision,  and  bleeding  may  be 
profuse  because  the  tumors  prevent  the  uterine  wall  from  retract- 
ing and  contracting  firmly. 

Cervical  fibroids  are  very  rare.  They  may  be  usually  removed 
per  vaginam  and  pregnancy  may  not  be  interrupted.  Even  a 
submucous  fibroid  polypus  projecting  into  the  cervix  may  some- 
times be  removed  without  rupture  of  the  amniotic  membrane. 

(The  conduct  of  labor  in  cases  of  fibroids  will  be  considered 
later.)     (See  "  Pathology  of  Labor.") 

Carcinoma  Uteri. — In  the  great  majority  of  cases  cancer 
occurs  in  the  cervix,  and  this  form  need  only  be  considered  in  re- 
lation to  difficulty  in  labor.  The  disease  is  a  rare  complication  of 
pregnancy.  Cohnstein,  in  1873,  was  able  to  find  records  in  litera- 
ture of  only  127  cases  ;  Theilhaber,  in  1893,  found  165  references 
from  the  preceding  twenty  years.  Early  cancer  does  not  interfere 
with  conception,  whereas  advanced  cancer  certainly  does.  The 
disease  may  begin  in  pregnancy.  Its  progress  is  hastened  as  a 
result  of  gestation ;  the  tumor  is  softer  and  breaks  down  more 
easily  and  spreads  more  rapidly  to  other  tissues.  Hemorrhage 
and  foul  discharge  are  usually  well  marked.  The  woman's  life 
expectancy  is  much  shortened  by  gestation.  The  effect  of  the 
cancer  in  the  course  of  pregnancy  varies.  Frequently  abortion  is 
caused,  especially  when  the  disease  extends  above  the  cervix. 
According  to  Bar,  full  term  is  not  reached  in  two-thirds  of  the 
cases.  Frequently  the  fetus  dies.  Herman  gives  a  percentage  of 
42.8  in  premature  cases  and  21.7  in  full-time  cases.  Occasionally 
the  pregnancy  may  proceed  beyond  term  even  though  the  pains  of 
labor  may  have  taken  place  at  the  normal  period,  the  fetus  usually 
dying.  A  number  of  cases  die  undelivered  and  a  large  percentage 
immediately  after  delivery.  Cohnstein  found  that  out  of  126  cases, 
31  died  during  or  immediately  after  labor  and  42  during  the  puer- 
perium.  Of  1 16  infants,  only  42  were  born  alive.  (The  relation- 
ship of  carcinoma  to  full-time  labor  will  be  considered  in  a  later 
chapter.)  (See  "  Pathology  of  Labor.")  It  should  here  be  noted 
that  when  abortion  or  premature  delivery  occurs  the  undilatability 
of  the  cervix  may  prove  an  important  obstacle  to  the  escape  of 
the  uterine  contents.  In  some  cases  this  is  not  found,  the  friable 
tumor  tearing  readily.  Rupture  of  the  uterus  above  the  cervix 
may  sometimes  take  place  if  the  disease  has  extended  upward. 
Septic  infection  is  very  apt  to  occur  because  of  the  dirty  condition 
of  the  cervix  ;  this  is  a  frequent  cause  of  death.  Hemorrhage  and 
extravasation  bring  about  a  fatal  issue  in  other  cases. 

The  diagnosis  of  carcinoma  is  uncertain  in  the  early  stages  of 


328  AFFECTIONS   OF  THE   REPRODUCTIVE   SYSTEM. 

the  disease  ;  later  it  is  easy.  The  symptoms  and  signs  are  the  same 
as  are  found  in  the  non-pregnant  condition.  In  doubtful  cases  a 
small  portion  of  the  suspicious  part  of  the  cervix  should  be  re- 
moved for  microscopic  examination.  The  disease  must  be  diag- 
nosed from  chronic  inflammatory  changes  in  the  cervix,  mucous 
polypi,  simple  papilloma,  ulcerating  fibroid  polypus,  breaking-down 
mass  of  fibrin,  placenta  praevia,  and  incomplete  abortion. 

Treatment. — If  the  disease  is  recognized  early  in  the  first  four 
months  of  pregnancy,  abdominal  or  vaginal  hysterectomy  should  be 
performed.  If  the  disease  has  spread  beyond  the  cervix  into  other 
structures  only  the  uterine  contents  should  be  removed.  In  carry- 
ing out  this  procedure  there  may  be  much  hemorrhage  and  there  is 
great  risk  of  infection.  All  operative  procedures  should  be  preceded 
by  thorough  curettage  of  the  carcinomatous  tissue  and  the  applica- 
tion of  the  cautery  or  a  50  per  cent,  formahn  solution.  When  suf- 
ficient dilatation  of  the  cervix:  cannot  be  obtained  for  the  re- 
moval of  the  ovum,  vaginal  Csesarean  section  may  be  performed 
where  the  pregnancy  has  advanced  beyond  the  fourth  month, 
even  at  full  term,  the  uterus  being  removed  immediately  after  its 
evacuation.  Most  authorities  favor  the  deliveiy  of  the  viable  fetus 
in  advanced  gestation  by  the  natural  passage  if  the  condition  of 
the  cervdx  offers  no  hindrance  to  delivery,  or  by  abdominal  Porro- 
Caesarean  section  if  it  does.  The  latter  operation  must  be  pre- 
ceded by  thorough  curettage  and  cauterization  of  the  cancerous 
cervix  in  order  to  lessen  the  risk  of  infection.  In  some  cases  the 
mother  will  allow  no  interference  until  pregnancy  is  far  advanced, 
in  the  hope  of  obtaining  a  living  child.  The  relationship  of  cancer 
of  the  cer\ix  to  labor  will  be  considered  later.  (See  "  Pathology 
of  Labor.'") 

Cervical  Polypi. — Mucous  polypi  may  cause  hemorrhage 
during  pregnancy  ;  they  should  by  removed  by  twisting.  They 
are  never  large  enough  to  cause  obstruction  in  labor.  Fibroid 
polypi  of  the  cervix  are  very  rare.  If  they  cause  hemorrhage  or 
are  large  enough  to  obstruct  the  passage  in  labor  they  should  be 
removed. 

Prolapsus  Uteri. — Pregnancy  may  occur  in  a  uterus  already 
prolapsed  or  descent  may  take  place  after  pregnancy  has  com- 
menced owing  to  the  influence  of  one  or  more  of  the  causes  that 
lead  to  the  displacement  in  the  non-pregnant  state.  Generally  the 
organ  rises  gradually  after  the  fourth  month  of  pregnancy  as  the 
fundus  grows  into  the  abdomen.  Sometimes  incarceration  in  the 
pelvis  occurs  ;  this  is  most  apt  to  take  place  if  the  uterus  is  retro- 
verted  as  well  as  prolapsed.  Occasionally  the  organ  remains 
more  or  less  prolapsed  throughout  pregnancy,  though  it  may 
grow  upward  into  the  abdomen.  In  many  cases  the  appearance 
of  prolapse  is  exaggerated  by  marked  hypertrophic  elongation 
of  the  cervix. 


RETROVERSION  AND   RETROFLEXION.  329 

The  latter  condition  alone  may  be  found  in  pregnancy  and  may 
be  wrongly  diagnosed  as  prolapsus  uteri.  The  symptoms  vary 
considerably  and  are  similar  to  those  found  in  the  non-pregnant 
state — i.  c\,  bearing-down,  disturbances  of  micturition  and  defeca- 
tion, etc.  When  impaction  occurs  the  disturbances  are  similar  to 
those  described  in  connection  with  the  incarceration  of  the  retro- 
verted  gravid  uterus.  In  a  considerable  proportion  of  cases 
pregnancy  is  interrupted  in  the  early  months,  chiefly  owing  to 
congestion  and  hemorrhages  in  the  uterus ;  this  may  also  take 
place  in  the  late  months. 

Treatment. — When  the  condition  is  discovered  the  uterus 
should  be  elevated  by  suitable  postural  and  manual  manipulations. 
A  suitable  vaginal  pessary  should  then  be  used  to  prevent  the 
uterus  from  sinking.  It  should  be  worn  for  at  least  four  months, 
antiseptic  vaginal  douches  being  used  for  cleansing  purposes. 
The  woman  should  not  wear  corsets  and  should  suspend  her 
skirts  from  the  shoulders.  She  should  not  engage  in  work  that 
involves  straining,  lifting,  or  long  standing.  Each  day  she  should 
rest  for  several  hours  on  the  flat  of  the  back  or  with  elevated 
hips. 

In  some  cases  adhesions  prevent  the  elevation  of  the  uterus. 
This  complication  necessitates  either  abortion  or  abdominal  section 
for  the  purpose  of  freeing  the  adhesions  and  elevating  the  uterus. 
When  the  organ  is  impacted  in  the  pelvis,  abortion  should  be 
induced  if  attempts  at  elevation  fail.  If  the  uterus  become  infected 
vaginal  hysterectomy  should  be  performed. 

Retroversion  and  Retroflexion. — Backward  displacement 
of  the  gravid  uterus  is  most  frequently  found  in  women  in  whom 
the  non-pregnant  organ  was  similarly  displaced.  But  the  condi- 
tion may  arise  in  early  pregnancy  de  novo,  due  to  one  or  other  of 
the  causes  that  bring  it  about  at  other  times — e.  g.,  a  strain  or  fall, 
the  pressure  of  a  loaded  bowel  or  of  a  distended  bladder.  Some- 
times the  fundus  may  be  pushed  backward,  as  the  uterus  enlarges, 
by  the  projecting  promontory  of  an  anteroposteriorly  contracted 
pelvis.  Sometimes  the  displacement  may  be  due  to  the  presence 
of  a  tumor  in  the  pelvis — /.  c,  ovarian  cyst,  fibroid  of  the  anterior 
uterine  wall,  interfering  with  the  normal  upward  development  of 
the  uterus. 

Results — In  some  cases  the  displacement  is  gradually  righted, 
the  uterus  rising  above  the  brim  in  the  normal  manner.  Occa- 
sionally the  anterior  wall  of  the  uterus  develops  above  the  brim, 
the  rest  remaining  below  as  a  posterior  sacculation  or  diverticulum, 
more  or  less  developed.  The  most  serious  result  is  impaction  of 
the  whole  uterus  in  the  pelvis.  This  is  most  apt  to  occur  when 
the  pelvis  is  contracted  or  when  the  uterus  is  fixed  by  adhesions, 
though  it  does  not  necessarily  take  place  when  the  latter  are 
present,  since  they  may  become  stretched   or  torn,  allowing  the 


330 


AFFECTIONS    OF   THE   REPRODUCTIVE   SYSTEM. 


uterus  to  rise.  In  these  conditions  spontaneous  abortion  may 
take  place.  If  it  does  not  occur  and  the  uterus  becomes  incar- 
cerated the  rectum  and  bladder  are  greatly  interfered  with.  The 
urethra  is  compressed  against  the  pubes  and  the  bladder  becomes 
distended.  Infection  may  occur  and  bad  cystitis  follow  ;  gangrene 
may  take  place  and  a  large  portion  of  the  bladder-wall  may  be 
destroyed  and  discharged.  Sometimes  the  bladder  may  rupture. 
The  kidneys  and  ureters  may  become  infected.  The  uterus  may 
also  become  septic  or  gangrenous  and  peritonitis  develop ;  the 
rectum  and  vagina  may  also  become  gangrenous  and  may  rupture. 
The  nerves  and  vessels  of  the  pelvis  may  be  subjected  to  great 
pressure  and   marked   edema  and   congestion  of  the  vulva  and 

lower  limbs  may  be  produced.     General 
r.---  rn     ggpsis^  pyemia,  or  uremia  may  develop. 

Symptoms. — In  early  cases  of  back- 
ward displacement  of  the  uterus  there 
may  be  no  symptoms  or  those  found 
ordinarily  in  the  non-pregnant  state — 
/.  c,  backache,  bearing  down,  frequency 
of  micturition,  etc.  Reflex  vomiting  or 
other  neuroses  may  be  present.  As  the 
growing  uterus  fills  the  pelvis,  vesical  and 
rectal  disturbances  increase.  Micturition 
may  be  painful  or  may  be  impossible. 
The  urine  may  be  passed  very  often 
when  the  bladder  is  much  distended. 
Sometimes  a  period  of  retention  is  fol- 
lowed by  much  dribbling.  As  the  blad- 
der rises  into  the  abdomen  it  tends  to 
lift  the  cervix,  so  that  the  pressure  of 
the  latter  on  the  urethra  is  relieved  for  a 
time,  allowing  some  escape  of  urine. 

Constipation  is  common,  though  for 
a  time  there  may  be  an  irritative  diarrhea. 
When  the  uterus  is  incarcerated  a  bowel  movement  may  be  impos- 
sible. Pressure  on  nerves  may  lead  to  weakness  and  pains  in  the 
lower  limbs,  and  walking  may  produce  much  displacement.  Pelvic 
distress  and  pain  are  usually  constant  when  impaction  occurs. 

Physical  Signs. — In  the  early  stages  of  backward  displace- 
ment various  positions  of  the  uterus  may  be  found.  The  fundus 
may  be  placed  high  or  low  in  the  hollow  of  the  sacrum ;  some- 
times it  may  be  found  in  the  lowest  portion  of  the  pouch  of 
Douglas.  The  cervix  is  also  variously  placed  ;  it  may  be  directed 
•downward  and  forward  or  forward  and  upward,  in  extreme  cases 
being  found  above  the  symphysis,  scarcely  within  reach  of  the 
finger.  The  fundus  may  be  raised  by  bimanual  manipulations 
imless  it  is  held  by  adhesions  or  is  impacted,  especially  when  the 


Fig.  137. — Pregnant  uterus 
of  early  part  of  third  month 
(Braun's  frozen  section),  with 
retroversion :     D,   D,    Decidua 


RETROVERSION  AND    RETROFLEXION.  33 1 

patient  is  placed  in  the  genu  pectoral  position.  When  the  bladder 
is  distended  it  forms  a  tumor  in  the  lower  abdominal  region, 
which  may  rise  as  high  as  the  umbilicus  or  even  higher.  When 
cystitis  occurs  the  urine  is  altered  accordingly.  When  the  wall 
necroses,  portions  of  the  mucosa  or  of  the  mucosa  and  mus- 
culature may  be  passed  in  the  urine  or  they  may  completely 
block  the  urethra.  Sometimes  from  the  infected  bladder-wall  an 
abscess  may  form  in  the  anterior  abdominal  wall  and  a  urinary 
fistula  may  develop.  When  the  uterus  is  incarcerated  there  may 
be  marked  edema  of  the  vulva  and  congestion  of  vessels  both  in 
the  vulva  and  anus.  The  same  changes  maybe  found  in  the 
lower  limbs.  When  infection  or  gangrene  takes  place  the  system 
shows  the  changes  due  to  toxic  absorption.  Acute  peritonitis 
may  be  present,  and  may  or  may  not  follow  rupture  of  the  bladder 
or  uterus. 

Treatment. — {a)  When  the  Uterus  is  )iot  Incarcerated. — In 
every  case  thorough  examination  of  the  patient  should  be  made 
before  treatment  is  carried  out,  anesthesia  being  used  if  necessary, 
in  order  that  an  exact  knowledge  of  the  pelvic  viscera  may  be 
obtained.  If  this  rule  be  not  observed  serious  troubles  may 
result.  Thus,  one  instance  is  known  to  the  author  of  a  case  com- 
plicated by  an  ovarian  abscess.  The  latter  was  not  discovered 
before  manipulations  were  employed  to  replace  the  uterus,  and 
was  ruptured,  leading  to  a  fatal  peritonitis.  The  bladder  should  be 
catheterized,  and  the  bowel  washed  out  by  means  of  a  long  rectal 
tube  before  replacement  of  the  uterus  is  attempted.  Reposition 
may  usually  be  effected  by  putting  the  patient  in  the  genupectoral 
position.  When  the  first  attempt  is  not  successful  the  woman 
should  be  sent  to  bed  and  kept  on  a  low  diet  thirty-six  or  forty- 
eight  hours  before  the  manipulations  are  again  repeated.  Occa- 
sionally the  reposition  may  be  assisted  if  the  cervix  be  pulled 
downward  as  the  fundus  is  pushed  up  per  rectum  or  per  vaginam. 
This  should  be  carefully  done  to  avoid  tearing.  When  adhesions 
are  present  manipulations  must  be  carefully  conducted.  If  they 
are  not  extensive  they  may  be  gradually  stretched  and  divided  by 
gentle  massage  in  the  genupectoral  position  or  by  tampons  placed 
frequently  in  the  vagina.  Instead  of  tampons  a  rubber  bag  may 
be  introduced  into  the  vagina  or  rectum  and  be  left  distended  for 
six  hours.  Sinclair  recommends  the  use  of  a  watch-spring  vaginal 
pessary,  the  patient  lying  on  her  side,  with  the  hips  elevated.  If 
the  adhesions  do  not  yield  on  account  of  their  size  or  number 
abdominal  section  should  be  performed,  in  order  to  break  up  the 
adhesions  and  to  replace  the  uterus.  Jacobs  has  carried  out  repo- 
sition in  1 1  cases  without  mortality.  In  10  pregnancy  continued 
to  full  term  ;  in  i  only  abortion  took  place,  four  days  after  opera- 
tion. If  there  be  a  suspicion  of  infection  in  the  tubes  or  ovaries 
manipulations  should  not  be  carried  out.     Neither  should  this  be 


zz^ 


AFFECTIONS   OF   THE   REPRODUCTIVE   SYSTEM. 


attempted  when  the  displacement  is  complicated  by  a  tumor  of 
some  size.  If  the  patient  will  not  agree  to  this  procedure,  abor- 
tion must  be  induced.  In  all  cases  in  which  reposition  is  per- 
formed a  suitable  vaginal  pessarj^  should  be  introduced  and  worn 
until  the  end  of  the  fourth  month. 

{b)  After  hicarceratiou. — When  the  uterus  is  incarcerated  most 
authorities  recommend  that  pregnancy  be  terminated  as  follows  : 
The  bladder  should  be  emptied,  in  the  first  place.  This  is  best 
effected  by  means  of  a  long  metal  catheter.     \Mien  the  urethra 

is  much  compressed  by 
the  cervix  the  latter,  if  it 
can  be  reached,  may  be 
pulled  backward  with  a 
volsella  while  the  catheter 
is  passed.  Sometimes 
these  methods  may  fail 
and  it  is  necessary  to  per- 
form suprapubic  puncture 
of  the  distended  bladder. 
The  uterus  may  be  aborted 
through  the  cervical  canal ; 
but  if  this  be  ver}-  high  and 
inaccessible  it  is  advisable 
first  of  all  to  evacuate  the 
liquor  amnii  by  puncture  of 
the  uterine  body  through 
the  posterior  fornix.  Then 
it  is  usually  possible  to 
draw  down  the  cervix  and 
carr}'  out  the  abortion. 

Recently  abdominal  sec- 
tion has  been  successfully 
employed  to  raise  an  in- 
carcerated uterus  out  of 
the  pelvis,  pregnancy  con- 
tinuing satisfactorily  after- 
ward. Such  a  procedure  should  always  be  recommended  as  an 
alternative  to  the  induction  of  abortion  in  case  the  patient  and  her 
husband  desire  gestation  to  continue.  The  section  should,  how- 
ever, only  be  carried  out  if  the  conditions  permit  of  its  performance 
by  an  expert. 

Rupture  of  the  bladder  demands  early  abdominal  section. 
Gangrene  of  the  uterine  wall  is  very  fatal,  and  demands  emptying 
and  vaginal  removal  of  the  organ  if  possible. 

Anteversion. — Normally  in  pregnancy  the  body  of  the 
uterus  presses  on  the  bladder  in  the  early  months,  so  as  to  be 
felt   with    o-reat   ease   through   the    anterior  vaeinal   wall.     This 


Fig.  138.  —  Frozen  section  of  retroverted 
uterus  of  three  .'ind  a  half  to  four  months. 
Death  from  rupture  of  bladder  {Arch.  f.  Gvii., 
Band  41,  Taf.  8,  f.  11. 


LA  TERAL    DISPLA  CEMENTS  A  CCULA  TION.  333 

explains  the  frequency  of  micturition  that  is  so  often   found  at 
this  period. 

When  adhesions  exist  between  the  uterus  and  bladder  the 
latter  viscus  may  be  greatly  interfered  with,  and  as  the  uterus 
rises  into  the  abdomen  may  be  markedly  dragged  on.  Micturi- 
tion disturbances  may  thus  be  very  pronounced.  Extreme  ante- 
version  is  found  when  pregnancy  takes  place  in  a  uterus  that  has 
been  fixed  to  the  vagina  or  bladder  by  operation,  the  pregnant 
organ  remaining  anteverted,  being  prevented  from  rising  normally. 
In  advanced  pregnancy  abdominal  swellings  or  spinal  kyphosis 
may  force  the  fundus  of  the  uterus  abnormally  forward.  The 
most  frequent  cause  is  laxity  of  the  abdominal  wall,  associated 
with  separation  of  the  recti  muscles.  The  uterus  may  fall  for- 
ward between  the  muscles  in  extreme  cases  so  that  it  is  at  right 
angles  to  the  long  axis  of  the  spinal  column.  This  condition  is 
aggravated  when  the  waist  is  constricted  by  a  corset  or  skirt  bands 
or  by  the  lifting  of  heavy  weights. 

Treatment. — In  early  pregnancy,  when  discomfort  is  caused 
by  abnormal  anteversion  of  the  uterus,  some  relief  may  be  afforded 
if  the  patient  gives  up  the  wearing  of  corsets  and  supports  her 
skirts  from  the  shoulders.  A  Hodge  vaginal  pessary  may  also  be 
helpful  by  raising  the  uterus  as  a  whole.  When  adhesions  exist 
vaginal  tampons  may  be  employed  or  careful  massage  may  be 
made  through  the  anterior  fornix.  When  no  benefit  is  obtained 
by  these  measures  it  may  be  necessary  to  perform  abdominal 
section  in  order  to  separate  adhesions  and  elevate  the  uterus  ; 
otherwise  abortion  may  be  carried  out.  In  the  second  half  of 
pregnancy,  anteversion  due  to  a  lax  abdominal  wall  may  be  bene- 
fited if  the  patient  wears  a  broad  silk-elastic  belt  and  gives  up 
constricting  her  waist  with  corset  or  skirt  bands. 

I/ateral  displacement  of  the  uterus  may  be  congenital  in 
origin.  The  whole  organ  may  lie  near  one  side  of  the  pelvis  or 
the  fundus  only  may  be  inclined  toward  it.  The  displacement  may 
also  be  produced  by  inflammatory  adhesions  or  by  the  pressure 
of  a  pelvic  or  abdominal  swelling.  When  one  horn  is  imperfectly 
developed  the  main  portion  of  the  uterus  lies  lateriverted. 

Hernia. — The  pregnant  uterus  may  sometimes  develop  in  a 
ventral  or  inguinal  hernia,  rarely  in  the  latter.  The  most  fre- 
quent form  is  that  which  develops  in  connection  with  separation 
of  the  recti  muscles,  and  has  been  referred  to  in  considering  ante- 
version of  the  uterus. 

Treatment. — The  uterus  should  be  replaced,  and  kept  in 
position  by  a  broad  silk-elastic  belt.  If  reposition  is  impossible 
the  uterus  should  be  emptied  or  abdominal  section  carried  out,  in 
order  to  replace  the  organ  or  to  deliver  the  fetus  by  the  Caesarean 
operation. 

Sacculation. — This  condition  is  also  described  as  "  retrover- 


334  AFFECTIOXS    OF   THE   REPRODUCTIVE   SYSTEM. 

sion  of  the  gravid  uterus  at  term  "  and  "  sacciform  uterus."  It  is 
usuall}'  first  recognized  in  advanced  pregnancy,  and  consists  of 
an  abnormal  development  of  the  posterior  wall  of  the  uterus  into 
the  pouch  of  Douglas,  whereby  the  vagina  is  pushed  downward 
and  forward.  This  may  go  on  to  such  an  extent  that  the  sac- 
culation may  fill  almost  the  entire  pelvis.  The  cervix  may  be 
pushed  high  above  the  pubes,  and  the  vagina  may  be  so  com- 
pressed as  not  to  admit  more  than  one  finger.  The  bladder  is 
usually  drawn  into  the  abdomen  and  the  urethra  is  compressed 
against  the  pubes,  resulting  in  retention  of  urine  and  distention  of 
the  bladder.  The  rest  of  the  uterus  may  develop  normally  above 
the  brim. 

Posterior  sacculation  may  sometimes  develop  in  a  retroverted 
gravid  uterus  impacted  in  the  pelvis,  in  a  uterus  held  down  by 
adhesions,  in  one  complicated  by  a  large  fibroid  tumor  of  the 
anterior  wall,  or  in  one  whose  upward  extension  is  prevented  by  a 
tumor  outside  of  the  uterus.  The  condition  leads  to  marked 
pressure  symptoms ;  its  diagnosis  is  difficult.  The  sacculated  portion 
may  be  mistaken  for  an  ectopic  gestation  or  for  an  ovarian  tumor. 
The  removal  of  the  fetus  b}-  abdominal  Cesarean  section  is 
advisable. 

It  is  interesting  to  note  that  when  pregnancy  occurs  in  a  uterus 
held  in  an  anteverted  position  by  a  former  vaginal  or  ventral 
fixation  a  sacculation  of  the  posterior  wall  containing  the  ovum 
may  de\-elop  upward,  while  the  anterior  wall  remains  unexpanded 
as  a  thick  mass  immediately  above  the  cervix. 

Rupture  of  the  Uterus  during  Pregnancy. — Rupture  of 
the  uterus  in  pregnancy  is  very  rare.  In  306  cases  of  rupture 
collected  by  Trask  only  38  were  related  to  pregnancy,  the  rest  to 
labor.  In  12  of  these  the  accident  occurred  during  the  first  six 
months,  in  26  at  term.  Spontaneous  rupture  is  very  infrequent ; 
in  Trask's  38  cases  it  was  noted  only  in  14,  pregnancy  being  nearly 
always  in  an  advanced  stage.  It  has,  however,  been  described  in 
the  fourth  month.  It  has  been  reported  as  taking  place  during 
rest,  though  usualh'  during  or  after  exertion,  not  necessarily  ex- 
cessive— /.  r.,  vomiting,  walking,  bathing,  working.  In  some  cases 
the  uterine  wall  has  been  abnormal — c.  g.,  thinned,  due  to  mal- 
formation or  to  stretched  cicatricial  tissue  that  has  followed  a 
previous  incision  or  wound  of  the  uterus ;  weakened  by  new 
growths — viz.,  cancer  and  fibroid,  or  by  fatty  degeneration.  In 
some  instances  rupture  of  an  interstitial  gestation  has  been  un- 
doubtedly reported  as  rupture  of  a  normal  pregnant  uterus.  In  a 
number  of  cases  it  is  possible  that  the  rupture  has  been  initiated 
by  the  passage  of  an  instrument  into  the  uterus  for  the  purpose 
of  inducing  abortion.  The  majority  of  ruptures  in  pregnancy  are 
due  to  traumatism — i.  c,  a  blow,  fall,  or  marked  compression  of 
the  abdomen.     In  several  instances  the  uterus  has  been  perforated 


INTRAPERITONEAL    INFLAMMATIONS.  335 

through  the  abdominal  wall  by  a  sharp  instrument,  stake,  or  cow's 
horn.  In  other  cases  rupture  has  followed  criminal  or  legitimate 
instrumental  attempts  to  induce  labor  by  the  vaginal  route. 

The  site  and  extent  of  the  rupture  vary  according  to  the  cause. 
In  spontaneous  cases  any  part  of  the  wall  may  be  torn  when  it  is 
altered  by  disease — i.  t\,  carcinoma.  While  in  labor  it  is  the  lower 
uterine  segment  that  is  most  frequently  torn,  in  pregnancy  this  is 
not  the  rule.  In  17  cases  of  rupture  during  gestation  reported  by 
Lewers  the  fundus  was  the  site  of  the  lesion.  The  results  of 
rupture  vary.  The  ovum  or  part  of  it  may  be  expelled  into  the 
abdominal  cavity,  the  patient's  life  being  endangered  from  loss  of 
blood.  Generally  the  hemorrhage  is  more  or  less  checked  by 
retraction  of  the  uterine  muscle.  Death  of  the  fetus  usually  occurs 
and  peritonitis  may  develop.  Rarely  the  fetus  may  escape  in  the 
amnion  and  continue  to  develop,  the  membranes  becoming  ad- 
herent to  the  peritoneum,  the  placenta  remaining  in  the  uterus. 
Leopold  has  described  such  a  case  in  which  rupture  took  place  in 
the  fourth  month,  the  fetus  escaping  in  its  membranes  into  the 
peritoneal  cavity,  the  placenta  remaining  in  the  uterus  ;  the  gesta- 
tion advanced  until  the  end  of  the  eighth  month,  when  death  of 
the  fetus  occurred. 

After  rupture  the  viscera  may  enter  the  uterine  cavity,  obstruc- 
tion of  the  bowel  sometimes  resulting.  Strangulation  has  led  to 
perforation  and  the  establishment  of  a  utero-intestinal  fistula.  In 
some  cases  the  uterine  contents  may  escape  into  the  extraperitoneal 
tissue  between  the  layers  of  the  broad  Hgaments.  When  rupture 
occurs  in  early  pregnancy  it  is  most  apt  to  be  regarded  as  a 
ruptured  ectopic  gestation.  It  has  also  been  diagnosed  as  a  case 
of  acute  poisoning.  Indeed,  abdominal  section  may  be  necessaiy 
to  establish  its  real  nature.  In  advanced  pregnancy  the  lesion  may 
be  mistaken  for  intra-uterine  hemorrhage  associated  with  separa- 
tion of  the  placenta.  It  may  also  be  regarded  as  a  case  of  rupture 
of  intestine,  spleen,  or  other  viscera.  (See  "  Rupture  of  the  Uterus 
in  Labor.") 

Intraperitoneal  Inflammations. — An  acute  pelvic  inflam- 
matory process  rarely  develops  de  novo  in  pregnancy.  Sometimes 
this  maybe  due  to  an  appendicitis,  salpingitis,  or  ovaritis  ;  generally 
such  attacks,  when  occurring  in  the  pelvic  structures,  are  exacer- 
bations of  previous  processes.  More  commonly  pregnancy  is 
accompanied  with  old  chronic  inflammatory  remains  in  the  shape 
of  adhesions  of  appendages,  bowel,  omentum,  etc.  These  tend  to 
become  stretched  as  the  uterus  grows  and  they  may  break.  Some- 
times a  distended  tube  or  ovary  may  rupture.  Adhesions  may 
prevent  the  uterus  from  rising  out  of  the  pelvis,  and  thus  may 
lead  to  its  impaction,  or  may  cause  abortion.  The  symptoms  are 
the  same  as  are  found  in  the  non-pregnant  state.     Reflex  phe- 


336  AFFECTIONS    OF   THE   REPRODUCTIVE   SYSTEM. 

nomena  are  usually  more  marked.  Sometimes  the  rupture  of 
adhesions  or  of  a  tubal  or  ovarian  swelling  may  cause  shock. 

The  treatment  of  these  conditions  has  not  yet  been  placed  on 
a  satisfactory  basis.  In  acute  cases  it  is  the  same  as  in  the  non- 
pregnant state.  In  chronic  conditions  very  little  can  be  done  by 
local  minor  measures.  Vaginal  tampons  and  gentle  vaginal  and 
rectal  massage  are  recommended  by  many,  but  are  not  of  much 
value  and  may  cause  abortion.  Careful  dieting  and  regulation  of 
the  bowels  are  important.  The  woman  should  not  engage  in 
much  exertion,  should  avoid  tight  clothing,  and  ought  to  rest  a 
great  deal,  exercise  being  obtained  by  regular  massage.  Where 
the  adhesions  cause  much  distress  or  interfere  with  the  proper 
expansion  of  the  uterus  the  induction  of  abortion  is  usually  re- 
garded as  the  last  resort,  though  abdominal  section  would  be 
justifiable  for  the  purpose  of  removing  the  adhesions  or  diseased 
structures.  Celiotomy  is  advisable  if  a  tubal  or  ovarian  swelling 
is  likely  to  interfere  mechanically  with  labor  or  if  it  contains  a 
fluid  that  is  not  certainly  sterile.  Such  swellings  may  rupture  in 
pregnane}"  or  labor  with  serious  consequences,  and  should,  there- 
fore, be  remox^ed  as  early  as  possible  in  pregnancy. 

Appendicitis. — This  complication  of  pregnancy  has  only 
been  described  in  literature  within  recent  years.  Munde  was  the 
first  to  call  attention  to  the  condition  in  America.  In  1897  Abra- 
hams collected  1 1  cases  reported  by  American  writers  and  added 
4  observed  by  himself  Since  that  time  various  other  papers  have 
appeared.  In  Europe  Pinard,  Vina}',  and  a  few  others  have  col- 
lected cases.  It  is  veiy  probable  that  the  disease  is  much  more 
frequent  than  is  suspected,  being  very  often  overlooked.  It  ma}" 
occur  for  the  first  time  or  as  a  recurrent  attack,  and  may  develop 
during  pregnane}',  labor,  or  the  puerperium.  According  to 
Donoghue,  80  per  cent,  of  the  reported  cases  of  acute  appendicitis 
have  occurred  during  the  first  six  months  of  pregnanc}\  It  is  a 
more  serious  disease  than  in  the  non-pregnant  state.  Premature 
emptying  of  the  uterus  is  apt  to  be  caused,  and  in  some  cases  in- 
fection of  the  uterus  and  contents  ma}"  spread  from  the  diseased 
appendix.  The  fetal  death  rate  is  high.  Labor  may  seriously 
complicate  the  disease,  especially  if  the  appendix  be  adherent  in 
the  neighborhood  of  the  uterus.  Owing  to  the  great  risk  both 
to  mother  and  fetus  that  may  result  from  acute  appendicitis  in 
pregnancy,  it  is  advisable  that  a  non-pregnant  woman  who  has  had 
a  definite  attack  should  have  appendectom}"  performed  before  she 
becomes  pregnant.  When  an  attack  develops  in  a  pregnant 
woman  this  operation  is  also  indicated,  as  being  less  risky  than 
non-interference. 

The  incision  preferred  by  the  author  is  an  oblique  one,  parallel 
to  Poupart's  ligament  on  the  right  side  and  about  2\  in.  above  it, 
Avhich  divides  the  anterior  sheath  of  the  rieht  rectus  and  the  fascia 


PREGNANCY  AFTER    OPERATIVE   MEASURES.  337 

external  to  it  for  an  inch  or  more.  This  incision  is  stretched 
widely  and  the  rectus  muscle  is  divided  vertically,  the  two  portions 
being  pulled  apart.  The  peritoneal  cavity  is  then  opened  and  the 
appendix  removed.  The  incision  in  the  peritoneum,  rectus,  and 
fascia  are  closed  independently  with  catgut.  In  this  way  a  firm 
abdominal  wall  is  left,  the  liability  to  rupture  being  very  slight. 

Intestinal  Obstruction. — Rarely  in  labor  may  the  intestine 
be  interfered  with  so  as  to  cause  symptoms  of  obstruction.  This 
may  occur  as  a  result  of  pressure  and  straining  if  a  hernia  exists 
in  any  part.  It  may  be  caused  by  the  constriction  of  adhesions 
tightened  as  a  result  of  the  changed  size  and  position  of  the  uterus 
resulting  from  labor.  Gangrene  of  the  bowel  and  death  may 
follow.  Early  operation  is  indicated.  Vuic  has  reported  a  case 
of  intestinal  trouble  in  a  woman  three  months  pregnant,  due  to 
an  omental  tumor.  He  removed  the  latter  and  1 3^^  in.  of  small 
intestine.  Peritonitis  followed,  but  the  woman  recovered  and 
pregnancy  continued. 

Carcinoma  of  the  Rectum. — Endelmann  has  collected  13 
reported  cases  of  this  condition.  In  7  the  fetus  was  removed  by 
Caisarean  section.  When  the  disease  is  discovered  in  pregnancy 
and  is  operable  the  uterus  should  be  emptied  and  the  cancer  re- 
moved afterward.  If  it  is  inoperable  it  may  be  advisable  to  allow 
the  pregnancy  to  continue,  so  that  Csesarean  section  may  be  per- 
formed and  a  living  child  obtained. 

Pregnancy  after  Operative  Measures  for  Retroversion 
of  the  Uterus. — It  is  too  soon  to  speak  decisively  with  regard 
to  the  various  operative  measures  at  present  practised  for  posterior 
displacements  of  the  uterus,  but  sufficient  statistics  have  been 
published  to  warrant  the  following  statements  : 

The  Adams-Alexander  operation  has  no  deleterious  influence 
on  the  course  of  pregnancy  or  labor.  The  shortened  ligaments 
stretch  and  allow  the  uterus  to  rise  normally.  As  to  the  condition 
of  the  uterus  after  labor  there  is  little  information  ;  several  cases 
have  been  reported  in  which  the  organ  was  found  to  be  normally 
placed.  The  author  has  observed  several  in  Avhich  displacement 
of  the  uterus  returned.  All  other  operations  for  shortening  the 
round  ligament  by  vaginal  or  abdominal  section,  whatever  be  the 
method  employed — /.  c,  folding  the  ligament  on  itself,  implanting 
it  in  a  new  part  of  the  abdominal  wall,  or  attaching  it  to  the  back 
of  the  uterus,  do  not  tend  to  complicate  pregnancy  or  labor. 

After  ventrosuspension,  where  the  uterus  is  kept  to  the  front 
by  a  fibrous  ligament,  pregnancy  usually  develops  normally.  The 
uterus  rises  without  interference  because  the  fibrous  band  stretches 
or  breaks.     Labor  is  not  necessarily  abnormal. 

After  delivery  the  fibrous  ligament  remains  stretched  or  broken, 
and  consequently  the  uterine  displacement  may  return. 

Ventral,  vaginal,  and  vesical  fixations  are  apt  to  interfere  with 
22 


338  AFFECTIONS   OF  THE   REPRODUCTIVE   SYSTEM. 

pregnancy  and  labor  in  a  considerable  percentage  of  cases.  I  have 
collected  554  reports  of  pregnancies  following  ventrofixation.  Of 
these,  341  were  normal  both  in  gestation  and  labor;  abortion  oc- 
curred in  61  ;  various  complications  were  present  in  152.  In  labor 
turning  was  necessary  igtimes,  forceps  28  times,  Cesarean  section 
10  times.  In  9  there  was  marked  inertia  of  the  uterus,  and 
in  4  severe  postpartum  hemorrhage.  Forty-seven  infants  and  9 
mothers  died. 

In  70  cases  of  pregnancy  following  vaginal  fixation,  39  were 
normal;  abortion  occurred  in  4.  In  labor  version  was  necessary 
4  times,  forceps  3  times,  Caesarean  section  12  times.  In  8  various 
other  complications  existed.  Seven  mothers  died.  In  the  face 
of  such  statistics  as  these,  all  operations  that  bring  about  a  fixa- 
tion of  the  uterus  in  women  who  are  likely  to  become  pregnant 
must  be  pronounced  unjustifiable. 

Of  the  different  methods  employed,  vaginal  fixation  appears  to 
be  the  worst.  When  pregnancy  takes  place  in  these  cases  the 
normal  expansion  of  the  uterus  is  prevented.  In  many  instances 
the  adherent  portion  is  stretched  or  broken  ;  otherwise  the  per- 
centage of  complications  would  be  much  greater.  When  the  organ 
remains  firmly  attached  the  fundus  is  unable  to  rise  and  dragging- 
pains  result.  The  uterine  cavity  is  apt  to  enlarge  by  stretching 
and  thinning  of  the  posterior  wall  (an  upward  sacculation,  as  it 
were),  the  anterior  wall  remaining  unexpanded  and  forming  a 
more  or  less  fixed  mass  above  the  cervix,  which  may  markedly 
interfere  with  the  size  of  the  birth  canal.  Frequently  the  cervix 
is  displaced  upward,  sometimes  being  drawn  so  high  as  not  to  be 
reached  with  the  finger.  This  constitutes  a  serious  complication 
in  labor. 

Ovarian  Tumor. — This  condition  is  rare  as  a  complication 
of  pregnancy.  There  is  no  ground  for  believing  that  pregnancy 
is  in  any  way  a  causal  factor  in  the  production  of  ovarian  tumors. 
They  are  not  found  more  frequently  in  women  who  have  been 
pregnant  than  in  nulliparae.  Indeed,  Sir  J.  Williams  states  that 
the  tumors  are  proportionately  far  less  frequent  in  the  married 
than  in  the  single.  There  is  no  proof  that  pregnancy  accelerates 
their  growth.  In  pregnancy,  as  in  the  non-pregnant  state,  some 
ovarian  tumors  grow  quickly,  others  slowly,  for  unknown  reasons, 
a  great  range  of  variations  being  found.  Sometimes  a  rapidly 
growing  tumor  may  increase  slowly  when  pregnancy  occurs, 
though  generally  the  same  rate  continues.  In  some  cases  a  slowly 
growing  tumor  may  continue-  steadily  before,  during,  and  after 
pregnancy.  In  other  cases  increase  in  size  may  occur  only  during 
a  portion  of  the  gestation  period  or  after  pregnancy.  Leopold 
has  stated  that  pregnancy  favors  malignant  growth  in  the  ovaries, 
and  Wernich  that  it  occa.sions  mahg^nant  degeneration  in   ovarian 


OVARIAN   TUMOR.  339 

cysts.     Williams  shows  that  there  is  no  foundation  whatever  for 
these  statements. 

Twisting  of  the  pedicle  may  occur  in  pregnancy  with  the  various 
sequelae  noticed  in  non-pregnant  women.  According  to  Williams, 
it  is  found  three  times  more  frequently  in  the  pregnant  than  in  the 
non-pregnant.  It  is  much  more  likely  to  take  place  when  the 
tumor  is  above  the  brim  than  when  it  is  below.  The  risk  of  rupt- 
ure of  the  cyst  is  very  slightly  increased  by  pregnancy ;  this 
accident  most  often  occurs  in  connection  with  delivery.  Abortion 
and  premature  labors  are  frequent,  though  it  is  not  possible  to 
state  from  an  analysis  of  published  cases  the  exact  percentage 
due  to  the  tumors.  It  must  be  remembered  that  though  an 
ovarian  cyst  complicates  pregnancy,  the  interruption  of  gesta- 
tion may  be  due  to  a  number  of  other  causes.  Williams  found 
that  in  461  pregnancies,  abortion  or  premature  labor  took  place 
in  58;  Remy  found  55  in  321  cases.  In  Williams's  cases  the  per- 
centage was  greater  with  multilocular  cysts  than  with  dermoids. 
It  was  large  in  cancerous  ovarian  growths.  Suppuration  in  a 
cyst  is  very  rare  in  pregnancy  ;  it  is  more  frequent  after  labor. 
Hemorrhage  into  the  cyst  is  also  rare.  Intestinal  obstruction  is 
very  unusual. 

Treatment. — An  ovarian  tumor  should  be  removed  by  ab- 
dominal section  in  pregnancy  unless  it  be  very  small  and  above 
the  pelvic  brim.  The  maternal  mortality  is  very  slight  after  this 
operation,  and  frequently  pregnancy  is  not  terminated.  The  older 
methods  of  dealing  with  these  cases  are  responsible  for  an  enor- 
mous death  rate.  In  Heilberg's  statistics  of  271  cases  there  was 
a  maternal  mortality  of  more  than  25  per  cent.,  and  a  fetal  mor- 
tality of  more  than  66  per  cent.  In  Williams's  series  of  461  cases 
the  former  was  25  per  cent.,  the  death  rate  being  as  large  in  the 
easy  cases  as  in  the  difficult  ones  ;  in  cases  requiring  little  or  no 
help  as  in  those  needing  the  most  skilful  assistance.  Few  of  the 
deaths  occurred  in  pregnancy  when  not  interfered  with.  One 
took  place  suddenly,  probably  from  rupture  of  the  cyst;  5  re- 
sulted from  suppuration  of  the  cyst.  The  great  majority  of  the 
deaths  occurred  at  or  after  labor  or  in  the  puerperium,  the  largest 
percentage  being  after  delivery.  The  chief  causes  of  death  are 
rupture  of  the  cyst,  septic  infection,  gangrene  of  the  cyst-wall, 
hemorrhage,  and  peritonitis.  Such  a  record  is  sufficient  to  dis- 
credit the  various  methods  employed  in  the  past — /.  e.,  tapping 
the  cyst,  inducing  abortion  and  labor,  delivering  by  version,  forceps 
and  craniotomy.  Removal  of  the  cyst  by  abdominal  section  is 
the  safest  method.  If  it  cannot  be  removed  without  performing 
Cassarean  section  the  latter  procedure  should  be  as  well  carried 
out.  (This  subject  will  again  be  considered  in  connection  with 
Dystocia.) 

Gordon,  in    1894,  collected    176  cases  of  ovariotomy  in  preg- 


340  DISEASES    OF   THE    OVUM. 

nancy.  Of  these  93.2  per  cent,  recovered.  In  69  per  cent, 
gestation  continued  to  full  term.  He  shows  that  in  the  most 
recent  years  the  percentage  of  recoveries  and  of  full-time  labors 
is  even  greater.  The  most  favorable  results  are  obtained  when 
the  operation  is  performed  in  the  first  four  months.  Of  12  cases 
of  double  ovariotomy  all  the  women  recovered,  but  abortion 
occurred  in  42  per  cent.  In  10  cases  c}-sts  of  broad  ligaments 
were  removed,  with  i  death  and  6  abortions.  Fehling  has  col- 
lected 266  cases  with  a  mortality  of  5.4  per  cent. ;  in  33  per  cent, 
of  the  cases  the  fetus  was  lost  through  abortion  or  premature 
labor. 


CHAPTER    XII. 
DISEASES  OF  THE  OVUM. 

AMNION. 

Hydramnion  (Hydramnios  ;  Polyhydramnios;  Dropsy 
of  the  Amnion). — This  is  the  condition  in  which  the  liquor 
amnii  is  in  excess  of  the  normal  quantity,  which  at  the  end  of 
pregnancy  averages  between  i  and  2  pints.  The  range  of  varia- 
tion is  considerable,  and  it  is  impossible  to  state  definitely  the 
frequency  of  moderate  degrees  of  increase,  especially  in  advanced 
gestation.  Neither  can  it  be  stated  how  much  fluid  is  necessaiy 
to  produce  well-marked  disturbances.  Undoubtedly  the  uterus 
and  abdomen  will  tolerate  in  one  woman  what  could  not  be  borne 
without  marked  disturbance  in  another.  The  amount  of  fluid 
noted  in  different  cases  varies  from  2  to  25  quarts. 

Associations. — H\'dramnios  is  more  frequent  in  multiparae 
than  in  primipara^.  It  often  occurs  in  twin  pregnancies,  especially 
in  those  of  uniovular  development ;  and  where  there  are  two 
amniotic  sacs  one  or  both  may  be  distended.  It  has  been  found 
in  anemic  and  weakly  Avomen  ;  in  those  with  dropsical  conditions  ; 
in  tuberculosis,  diabetes,  and  syphilis  (Winckel).  In  a  number  of 
instances  diseases  of  the  placenta  and  membranes  have  been 
described  ;  in  some  cases  edema  of  the  cord  and  placenta.  It 
has  sometimes  been  found  in  women  with  valvular  heart  disease. 
Frequently  fetal  anasarca,  ascites,  anencephalus,  spina  bifida,  or 
other  fetal  malady  is  present.  It  is  important,  however,  to  note 
that  in  a  large  number  of  cases  (44  per  cent,  according  to  Bar)  no 
maternal  or  fetal  peculiarity  can  be  found. 

Pathology. — The  origin  of  the  excessive  fluid  is  not  at  all 
definitely  known.  Theoretically  it  may  be  due  to  oversecretion, 
imperfect  absorption,  or  to  a  combination  of  these.     It  may  be 


HYDRAMNION.  34 1 

derived  from  maternal  or  fetal  sources  or  from  both  combined. 
That  the  normal  liquor  amnii  is  mainly  of  maternal  origin  seems 
now  well  established.  Zuntz's  experiment  of  injecting  sodium 
sulphindigolate  into  the  veins  of  a  pregnant  rabbit,  producing 
thereby  blue  coloration  of  the  amniotic  fluid  but  not  of  the  fetal 
kidneys,  points  strongly  in  this  direction.  The  contribution  of  the 
fetal  kidneys  has  always  been  believed  to  be  important,  but  Schal- 
ler's  experiments  greatly  discredit  this  belief  He  administered 
phloridzin  to  pregnant  women  and  tested  the  liquor  amnii  at 
various  periods  for  sugar.  As  the  glycosuria  caused  by  this  sub- 
stance is  produced  mainly  in  the  kidneys,  it  is  possible  to  estimate 
the  activity  of  the  fetal  kidneys.  (His  results  are  given  on  page 
85.) 

In  the  light  of  his  researches  it  is  extremely  probable  that  in 
hydramnios  the  increased  fluid  is  most  frequently  maternal  in 
origin.  Certain  it  is  that  dropsical  conditions  in  the  mother  are 
apt  to  be  associated  with  excess.  Fehling  has  noted  that  the 
more  hydremic  the  maternal  blood  the  more  abundant  is  the 
amniotic  fluid.  Indeed,  it  is  not  improbable  that  an  important 
factor  in  explaining  normal  differences  in  the  quantity  of  liquor 
amnii  in  pregnancy  is  a  variation  in  the  hydremic  condition  of  the 
maternal  blood.  As  to  the  relative  influence  of  overproduction 
and  deficient  absorption  nothing  can  be  said,  since  we  do  not 
know  the  relationship  between  normal  production  and  absorption. 
A.  R.  Simpson  thinks  that  another  important  factor  is  loss  of  tone 
in  the  uterine  wall.  This  suggestion  is  certainly  worthy  of  much 
consideration  in  view  of  the  frequency  of  hydramnios  in  multi- 
parse,  especially  in  those  who  have  born  several  children,  and  in 
multiple  pregnancies.  Many  believe  that  the  increased  amniotic 
fluid  is  derived  from  the  following  sources  : 

{a)  Altered  States  of  the  Circulation. — Some  have  noted  the  per- 
sistence of  the  early  subamniotic  vasa  propria  of  Jungbluth  in 
certain  cases  of  hydramnios  and  have  believed  the  increased  fluid 
to  have  arisen  by  exosmosis  from  them.  This  is  altogether  un- 
likely, because  in  most  cases  of  hydramnios  no  such  vessels  are 
found.  Then  it  is  known  that  vascularization  of  the  connective 
tissue  of  the  amnion  may  be  found  without  any  hydramnios. 

{6)  Others  believe  that  any  condition  that  can  raise  blood- 
pressure  in  the  umbilical  vein  and  vessels  of  the  villi  may  cause 
hydramnios.  Thus,  it  has  been  noted  in  some  cases  of  lesion  of 
the  fetal  heart,  of  tumors  of  the  fetus  obstructing  the  circulation, 
and  in  abnormal  conditions  of  the  cord — /.  r.,  marked  torsion,  etc. 
Brindeau  has  reported  a  case  occurring  at  the  fifth  month  where 
there  was  sarcoma  of  one  fetal  kidney.  The  umbilical  vein  was 
dilated,  and  when  fluid  was  injected  into  it  transudation  was  ob- 
served ;  the  fetus  was  ascitic  and  the  placenta  very  large.  It  is  to 
be  noted,  however,  that  these  conditions  may  exist  without  any 


342  DISEASES    OF   THE    OVUM. 

hydramnios  ;  consequently  it  is  impossible  to  have  any  accurate 
knowledge  of  their  importance  as  causal  factors. 

{c)  Excessive  Fetal  Urination. — That  abnormal  activity  of  the 
fetal  kidneys  may  sometimes  lead  to  hydramnios  is  possible, 
though  in  no  way  proved.  As  has  already  been  stated,  the  fetus 
probably  does  not  normally  excrete  urine  ///  iitero  until  the  proc- 
ess of  labor  begins.  Why  this  function  should  prematurely 
develop  (if,  indeed,  it  does),  leading  to  an  excessive  quantit}-  of 
liquor  amnii,  is  inexplicable. 

[a)  The  fetal  skin  may  occasionally  be  the  source  of  hydram- 
nios. This  view  is  pure  hypothesis  and  is  based  upon  the  very 
rare  finding  of  hydramnios  along  with  a  thickened  and  folded  con- 
dition of  fetal  skin.  Budin  has  noted  a  case  in  which  there  were 
abundant  nevi.  These  fetal  changes  may,  howe\er,  be  in  no  way 
connected  with  the  production  of  the  increased  amniotic  fluid. 

(r)  Alterations  in  the  amnion  are  stated  to  be  an  occasional 
cause.  Some  think  that  inflammation  of  the  membrane  may  pos- 
sibly explain  the  production  of  acute  hydramnios.  A  few  observers 
have  described  fissures  between  the  amniotic  cells  in  certain  cases, 
through  which  they  believe  the  fluid  entered  the  amniotic  sac.  In 
some  cases  the  placenta  is  large,  dropsical,  or  otherwise  altered, 
but  no  constant  alteration  is  found.  The  relationship  to  twin  preg- 
nancy is  of  interest.  The  greater  frequency  in  uniovular  develop- 
ment has  been  noted.  Where  two  amniotic  sacs  are  present  there 
is  usually  a  considerable  disproportion  in  the  sizes  of  the  fetuses. 
Hydramnios  occurs  in  the  sac  containing  the  larger  fetus.  In  the 
latter  h}-pertropiiy  of  various  organs  may  often  be  found,  espe- 
cially in  the  heart ;  also  in  the  kidneys,  liver,  or  spleen.  It  is  be- 
lieved by  many  that  the  cardiac  hypertrophy  causes  abnormal 
activity  of  the  kidneys,  thus  leading  to  hydramnios  ;  but  this  is 
not  proved.  Sometimes,  though  rarely,  both  amniotic  sacs  may 
contain  an  excessive  quantity,  even  though  one  fetus  is  not  much 
larger  than  the  other.  Hydramnios  may  also  be  found  where 
there  is  only  one  amniotic  sac. 

Physical  Signs  and  Symptoms. — The  disease  rarely  may  de- 
velop rapidly.  Usually  the  accumulation  of  fluid  takes  place 
slowly.  In  the  great  majority  of  cases  the  onset  is  noted  after  the 
fifth  month. 

The  uterus  is  larger  than  it  is  at  the  corresponding  period  in 
normal  pregnancy  and  generally  stands  at  a  higher  level ;  its  wall 
is  tenser  than  normal.  Fetal  parts  are  more  difficult  to  palpate 
and  the  heart  sounds  may  not  be  so  often  auscultated.  Fluctua- 
tion is  usually  easily  obtained.  It  is  of  great  importance  to  note 
that  the  normal  variations  in  the  consistence  of  the  uterine  wall 
may  be  absent  for  long  periods.  Hardening  may  not  be  felt  at  all 
in  a  series  of  examinations,  or  may  be  very  slightly  marked. 

In  acutely  developed  hydramnios  there  may  be  much  distress 


HYDRAMNION.  343 

and  pain  in  the  abdomen.  Vomiting  and  other  reflex  disturbances 
are  present.  In  the  ordinary  chronic  case  marked  trouble  usually 
develops  in  advanced  pregnancy,  though  there  are  many  varia- 
tions in  the  degree  to  which  patients  may  be  affected.  There  are 
gastro-intestinal  disorders,  difficulty  in  respiration,  and  frequency 
or  irregularity  of  cardiac  action  as  a  result  of  the  pressure  of  the 
large  uterus.  There  may  be  weakness  in  the  body  and  legs  and 
inability  to  move  about  with  any  ease.  Varices  and  edema  of  the 
lower  limbs,  vulva,  and  abdominal  wall  may  develop.  The  ab- 
dominal wall  is  greatly  thinned  and  the  linea  alba  markedly 
stretched,  so  that  the  recti  are  widely  separated.  Sometimes  spon- 
taneous reduction  of  the  hydramnios  occurs. 

Differential  Diagnosis. — In  the  early  months  the  conditions 
may  be  mistaken  for  pregnancy  with  hydatidiform  degeneration 
of  the  chorion.  Fluctuation  is  not  present  in  the  latter  condition, 
which  sooner  or  later  leads  to  escape  of  blood  from  the  cervix 
along  with  the  characteristic  vesicles.  When  the  swelling  is  large 
the  condition  may  be  readily  mistaken  for  ovarian  or  parovarian 
tumor.  Scott  Skirving  has  reported  an  interesting  case  in  which 
the  abdomen  was  opened  on  the  mistaken  diagnosis  of  ovarian 
cyst.  Pregnancy  continued,  the  hydramnios  slowly  disappearing, 
and  a  normal  delivery  occurred  at  term,  there  being  no  sign  of 
hydramnios.  Repeated  examinations  should  be  made  in  order  to 
determine  especially  the  presence  of  a  fetus,  and,  as  well,  other 
signs  of  pregnancy.  Ascitic  distention  of  the  abdomen,  especially 
associated  with  tubercular  or  malignant  masses,  may  simulate 
hydramnios,  the  swellings  sometimes  simulating  fetal  parts.  A 
di.stended  bladder  along  with  pregnancy  may  lead  to  a  diagnosis 
of  hydramnios.  Twin  pregnancy  may  sometimes  be  distinguished 
with  difficulty  from  it. 

Prognosis. — In  about  50  per  cent,  of  cases  pregnancy  ends 
prematurely.  The  fetus  is  often  born  dead,  sometimes  shrivelled 
or  macerated.  Out  of  33  cases,  McClintock  noted  9  dead-born  ; 
of  the  rest  which  were  born  alive,  10  died  within  a  few  hours. 
The  influence  of  hydramnios  on  the  fetus  is  not  known. 

Influence  on  Labor. — In  the  advanced  months  labor  is  usually 
slow,  the  pains  being  weak.  Malpresentations  and  malpositions 
are  frequent.  Sudden  escape  of  much  liquor  amnii  may  lead  to 
complete  inertia  of  the  uterus.  Rupture  of  the  uterus  has  been 
noted  in  several  cases.  In  the  third  stage  the  placenta  is  slow  in 
being  expelled,  and  on  account  of  uterine  weakness  there  is  great 
risk  of  hemorrhage.  The  danger  of  infection  is  also  greater  than 
in  a  normal  case. 

Treatment. — There  is  no  known  method  of  preventing  the  in- 
crease of  liquor  amnii.  In  cases  where  the  patient  is  fairly  com- 
fortable no  interference  is  necessary.  A  well-fitting  binder  may 
relieve  abdominal  distress  somewhat.     In  marked  cases,  when  the 


344  DISEASES   OF  THE    OVUM. 

mother's  health  is  much  affected,  it  is  advisable  to  draw  off  some 
of  the  liquor  amnii  with  a  small  trocar,  the  membranes  being- 
punctured,  if  possible,  above  the  level  of  the  os  internum.  Rarely 
this  procedure  is  followed  by  improvement  without  the  occurrence 
of  premature  labor.  Generally,  however,  the  latter  is  induced. 
The  viability  of  the  fetus  is  not  to  be  considered  in  cases  where 
the  mother's  condition  is  distressing. 

When  labor  takes  place  the  mother  must  be  attended  with 
great  care.  When  dilatation  of  the  cerxix  is  well  advanced  a 
quantity  of  amniotic  fluid  should  be  drawn  off  slowly  with  a  fine 
trocar.  If  dilatation  is  very  slow  it  may  be  promoted  by  artificial 
means.  Delivery  of  the  child  by  forceps  or  version  may  be  indi- 
cated. In  the  third  stage  artificial  remo\al  of  the  placenta  may 
be  necessar}'.  The  uterus  should  be  packed  with  gauze  for  twenty- 
four  hours  to  stimulate  the  organ  and  to  prevent  bleeding,  and 
large  doses  of  ergot  ma}'  be  administered. 

Oligohydramnion. — This  is  the  condition  in  which  there  is 
a  deficient  quantity  of  liquor  amnii.  Nothing  is  known  as  to  its 
etiology.  A  few  cases  have  been  described  in  which  oligohy- 
dramnios in  late  pregnancy  has  been  associated  with  absence  of 
one  or  both  fetal  kidneys  or  with  imperforate  urethra.  Gusserow 
and  others  believe  that  such  cases  are  proof  that  the  fetal  kidneys 
contribute  largely  to  the  liquor  amnii.  The  fetus  is  often  mal- 
formed as  a  result,  probably,  of  abnormal  pressure.  Imperfect 
nutrition  of  parts,  resulting  in  ulceration,  has  been  noted.  Anky- 
losis of  joints  and  fractures  of  bones  have  been  described. 

Amniotic  Adhesions. — Bands  of  various  shapes  and  sizes 
are  sometimes  found  passing  from  the  fetus  to  the  amnion,  gen- 
erally where  oligohydramnion  also  exists  ;  they  are  non-vascular. 
It  is  believed  that  they  arise  in  early  embr^'onic  life,  as  a  result  of 
deficiency  in  the  liquor  amnii,  the  surface  of  the  fetus  being 
thereby  allowed  to  come  in  contact  with  the  amnion,  union  occur- 
ring at  one  or  more  points.  As  the  ovum  develops  the  joined 
areas  stretch.  Berry  Hart  has  recently  advanced  the  view  that 
the  amniotic  cavity  is  formed  by  the  breaking  down  of  the  central 
portion  of  a  mass  of  epiblast  in  the  early  embryonic  area.  He 
considers  that  amniotic  bands  are  derived  from  unobliterated  por- 
tions. Sometimes  the  bands  break  across,  remaining  attached  by 
their  ends  to  the  fetus  or  amnion.  In  some  cases  they  may  cause 
damage  to  the  fetus.  The  umbilical  cord  may  become  twisted  in 
one  and  the  life  of  the  fetus  endangered.  Parts  of  the  fetus  may 
atrophy  from  constriction  by  a  band  ;  it  has  been  held  by  many 
that  amputation  of  a  limb  may  be  brought  about.  Various  mal- 
formations may  be  produced — e.  g.,  eventration,  anencephalus, 
encephalocele,  etc.  Several  cases  have  been  described  in  which 
localized  destruction  of  the  skin  has  resulted  from  the  traction  of 
an  adhesion,  an  appearance  like  an  ulcer  being  produced.     The 


HYDATIDIFORM  DEGENERATION.  345 

child  when   born  may  show   this   recently  formed  or  partly  cica- 
trized. 

Other  Variations  in  the  I/iquor  Amnii. — The  fluid  varies 
considerably  in  color  and  consistence.  Early  it  is  usually  dull 
grayish  white  ;  in  the  late  months  it  is  greenish,  the  color  varying 
according  to  the  amount  of  meconium  in  it.  In  consistence  it 
may  be  limpid  and  thin  or  thick  and  syrupy.  The  odor  is  usually 
only  slight,  but  it  may  sometimes  be  distinct  and  unpleasant. 
When  the  fetus  is  macerated  or  decomposition  has  set  in  the 
liquor  is  usually  very  dark-colored  and  may  have  a  bad  odor. 

CHORION. 

Hydatidiform  Degeneration  (Vesicular  Mole ;  Hy- 
datid Mole  ;  Cystic  Mole  ;  Uterine  Hydatid  ;  Dropsy  of 
the  Villi;  Myxoma  Chorii  Multiplex). — This  condition  is 
one  in  which  swellings  develop  on  the  chorionic  villi,  varying  in 
size  from  2  mm.  to  2  cm.  They  are  found  at  the  ends  of  villi  or 
in  any  part  of  their  extent ;  sometimes  several  enlargements  may 
form  like  a  chain  of  beads. 

'  On  microscopic  examination  there  is  found  to  be  marked  and 
irregular  proliferation  of  the  epithelial  covering  of  the  villi,  Lang- 
hans's  and  syncytial  layers,  especially  at  the  ends  of  the  villi.  In 
some  areas  the  former  or  the  latter  may  be  very  thinned  or  want- 
ing. The  epithelium  shows  vacuolation  and  granular  degenera- 
tion in  many  parts.  Syncytial  extensions  into  the  connective 
tissue  of  the  villi  have  been  described,  but  Findley  thinks  that 
this  appearance  may  be  merely  due  to  a  peculiarity  in  making  the 
section  ;  at  any  rate,  it  is  very  rarely  found.  The  wall  of  the 
uterus  tends  to  be  invaded  to  a  degree  not  found  in  normal  preg- 
nancy. 

The  interior  of  the  villus  varies  considerably.  The  connective 
tissue  is  of  the  mucoid  type,  and  is  best  marked  near  the 
periphery,  where  it  may  be  somewhat  compressed  concentrically. 
The  cells  may  be  greatly  separated  in  parts,  there  being  an  increase 
in  fluid  between  them.  In  large  swellings  no  cells  can  be  dis- 
tinguished, as  a  rule,  in  the  central  portions,  which  stain  faintly  or 
not  at  all. 

Findley  shows  that  granular  degeneration  occurs  in  the  cells, 
beginning  in  the  connective-tissue  core  of  the  villus  ;  as  it  disap- 
pears the  spaces  fill  with  fluid  containing  mucin  and  some  albumin. 
Rarely  it  is  slightly  tinged  with  blood. 

The  capillaries  of  the  altered  villi  are  usually  obliterated. 
There  is  no  evidence  that  the  change  is  a  primary  mucoid  degen- 
eration of  the  stroma,  as  described  by  Virchow.  Storch  has 
termed  it  a  "  cy.stoid  "  degeneration.  Various  workers  consider  it 
to  be  an  edema  associated  with  a  disturbed  circulation. 


346 


DISEASES    OF   THE    OVUM. 


There  can  be  little  doubt  that  the  most  prominent  feature  in 
the  disease  is  marked  proUferation  of  the  epithehum  of  the  villi. 
The  changes  in  the  stroma  are  probably  secondary  in  importance, 
though  they  are  usually  coincident. 

Marchand  believes  that  normally  the  fetal  blood  is  of  minor 
importance  in  supplying  nourishment  to  the  villi,  and  points  out 


Fig.  139. — Section  of  uterus  containing  a  hydatidiform  mole  (Bumm)  ;  a,  Vesicles 
extending  into  blood-sinuses  in  uterine  wall ;  b,  openings  of  maternal  blood-sinuses  ; 
c.  OS  internum  ;  d,  cervi.x  ;  e,  vesicles  extending  into  uterine  wall ;  f,  uterine  veins  and 
degenerated  chorionic  villi. 


that  in  the  absence  of  the  syncytium,  even  though  the  fetal  circu- 
lation be  intact,  there  is  likely  to  be  degeneration  in  the  stroma. 
He  holds  that  the  syncytium  exercises  an  influence  in  determining 
the  nourishment  of  the  villi  by  the  maternal  blood. 

Findley  believes    that    impaired    nutrition  from  the  maternal 
blood  favors  the  degenerative  changes  in  the  villi.     It  must  be 


HYDATIDIFORM  DEGENERATION.  347 

noted,  however,  that  in  every  case  of  normal  pregnancy,  degen- 
eration of  the  decidua  reflexa  and  impairment  of  the  maternal 
nutrition  supplied  to  the  villi  of  the  chorion  laeve  attached  to  it 
are  not  followed  by  the  changes  found  in  vesicular  mole,  but  by 
simple  atrophy  and  degeneration.  The  swellings  on  the  ends  of 
the  villi  may  extend  as  far  as  or  into  the  uterine  musculature; 
rarely  the  peritoneal  covering  may  be  perforated.  This  extension 
is  due  to  the  phagocytic  action  of  the  epithelium.  The  walls  of 
the  veins  and  sinuses  may  be  entered  and  portions  of  the  villi  may 
be  carried  away  in  the  circulation.  Several  specimens  have  been 
described  in  which  the  reflexa  in  early  pregnancy  was  perforated, 
the  swellings  on  the  villi  extending  into  the  space  between  it  and 
the  vera.  In  well-marked  cases  the  whole  mass  of  the  chorion 
reaches  the  size  of  a  cocoanut,  weighing  several  pounds.  Some- 
times hydramnios  is  also  present. 

The  disease  usually  begins  in  the  early  weeks  of  pregnancy. 
It  may  affect  both  the  chorion  frondosum  and  laeve,  in  part  or 
entirely.  In  some  cases  only  one  of  these  may  be  affected,  par- 
tially or  completely.  The  ovum  when  expelled  from  the  uterus 
presents,  therefore,  different  appearances  in  different  cases.  The 
effect  on  the  embryo  also  varies  considerably.  If  the  disease  be 
extensive,  particularly  if  the  chorion  frondosum  be  affected,  the 
embryo  dies  and  disappears.  When  only  a  small  part  is  affected 
its  life  may  not  be  endangered  and  it  may  reach  full  time.  In 
twin  pregnancy  the  degeneration  may  be  present  in  one  ovum  and 
absent  in  the  other.     It  may  occur  in  tubal  pregnancy. 

Etiology- — The  causation  of  this  disease  is  not  known. 
Findley  has  studied  210  cases,  and  finds  that  the  greatest  number 
occurred  between  the  ages  of  twenty  and  thirty,  the  extremes 
being  thirteen  and  fifty-eight  and  the  average  age  twenty-seven ; 
it  was  two  and  a  half  times  as  frequent  in  multiparae  as  in  primi- 
parae.  The  disease  may  sometimes  recur  in  one  or  more  suc- 
ceeding pregnancies.  No  general  or  local  maternal  diseases  can 
be  shown  to  influence  the  development  of  a  mole — /.  e.,  nephritis, 
cystic  ovaries,  endometritis. 

Results. — Early  expulsion  of  the  degenerated  ovum  may 
occur,  usually  between  the  third  and  sixth  months.  In  cases 
where  the  fetus  has  not  been  affected  owing  to  the  small  amount 
of  degeneration,  pregnancy  may  reach  term. 

A  few  cases  have  been  reported  in  which  the  mole  has  not 
been  expelled,  even  where  the  embryo  has  disappeared,  but  has 
remained  in  utero  several  weeks  beyond  the  period  of  normal 
pregnancy.  In  some  instances  they  have  been  described  as  being 
partially  expelled,  the  rest  remaining  in  the  uterus  for  years.  In 
some  cases  hemorrhage  may  be  so  excessive  as  to  endanger  the 
patient's  life;  during  expulsion  of  a  mole  this  danger  is  great. 
Occasionally  the  contractile  power  of  the  uterus  may  be  consid- 


348  DISEASES   OF  THE    OVUM. 

erably  weakened  ;  intraperitoneal  bleeding  may  sometimes  take 
place  as  a  result  of  perforation  of  the  uterine  wall  by  the  mole. 

If  all  the  vesicles  are  not  expelled  subinvolution  of  the  uterus 
results  ;  decomposition  may  take  place  in  the  portions  left  behind. 
In  recent  \'ears  it  has  been  shown  by  various  workers  that  remains 
of  a  vesicular  mole  may  give  rise  to  one  form  of  the  disease  known 
as  "  deciduoma  malignum."  ^Metastatic  growths  tend  to  develop 
in  the  vulva,  lungs,  and  other  parts,  in  which  there  ma\-  be  repro- 
ductions of  the  molar  structure. 

Symptoms  and  Physical  Signs. — In  the  earliest  stage  there 
is  no  indication  of  the  change.  Later  in  a  well-marked  case  it  is 
usual  to  note  that  the  uterus  increases  more  rapidh'  than  in  normal 
pregnancy.  Thus,  at  the  third  month  the  organ  may  be  as  large 
as  though  it  contained  a  fourth-  or  fifth-month  ovum.  Very  fre- 
quently hemorrhage  occurs ;  it  may  be  sudden  and  profuse,  or 
may  escape  in  driblets  either  as  pure  blood  or  serum  ;  when  the 
discharge  is  intermittent  the  inter\als  may  be  long  or  short. 
Vomiting  is  sometimes  present  and  may  be  \ery  severe.  Occa- 
sionally the  vesicular  masses  are  expelled  with  the  blood,  resem- 
bling "  white  currants  in  red-currant  juice."  As  a  result  of  the 
loss  of  blood  patients  often  become  very  much  debilitated.  Where 
rapid  increase  of  the  uterus  takes  place,  excessive  vomiting  has 
been  noted  in  a  {q.\\  cases. 

On  bimanual  examination,  when  the  condition  is  well  marked, 
the  uterus  has  a  firm,  somewhat  doughy,  boggy  feeling,  its  out- 
line being  occasionally  irregular ;  rarely  it  may  be  quite  hard. 
Poten  states  that  contractions  in  the  wall  may  be  irregular  and 
prolonged,  the  contracted  portions  being  sometimes  mistaken  for 
fibroids.  Sometimes  the  round  masses  of  the  mole  may  be 
palpated  when  they  develop  in  the  uterine  wall.  The  usual 
auscultatoiy  phenomena  of  pregnancy  are  generally  wanting ; 
ballottement  is  absent ;  fetal  parts  are  not  palpable. 

In  cases  where  the  mole  ceases  to  develop  and  is  not  expelled 
from  the  uterus  the  latter  is  smaller  than  it  should  be  for  the 
period  of  pregnane}'  represented.  Thus,  though  nine  months  may 
have  elapsed  since  conception,  the  uterus  may  only  be  as  high  as 
the  umbilicus. 

In  50  cases  collected  by  Kehrer  hemorrhages  occurred  in  41, 
being  very  severe  in  14.  In  20  there  was  abdominal  pain,  in  15 
edema  of  the  legs.  Debility  was  \'(txy  common.  Vomiting  was 
not  frequent.  Abortion  occurred  at  the  second  month  in  2  cases, 
at  the  fourth  in  15,  at  the  fifth  in  13  ;  only  2  went  to  term.  In 
45  cases  labor  was  completed  within  twenty-four  hours,  and  in 
two-thirds  within  six  hours.  In  most  cases  the  pains  were  strong 
or  moderately  strong.  In  more  than  half  the  cases  severe  flood- 
ing occurred  in  labor,  16  of  the  women   fainting.     In  two-thirds 


PLATE  g. 


<»<»  I®    '       9 


^% 


Fig.  I. — Altered  villus  in  hydatidiform  mole.      There  is  marked  irregular  develop- 
ment of  syncytium  (Findley). 


\"      <\ 


'  "      O       ,00*  ■      ^,  ,  C\ 

-  0  •.      »•'   'S 


•    «    »  O    '^  » 


<s»,'ifs;jl^»^^y 


P'lG.  2. — Altered  villus   in   hydatidiform  mole.     The  syncytial  layer  is  much  thick- 
ened (Findley). 


VESICULAR   MOLE.  349 

the  puerperium  was  normal  and  recovery  rapid.  Among  the  rest 
there  were  prolonged  debility,  infection,  etc.     No  death  occurred. 

Differential  Diagnosis. — The  diagnosis  may  be  very  diffi- 
cult in  some  stages.  Thus,  the  rapid  increase  in  size  may  simu- 
late hydramnios.  When  early  hemorrhages  occur  ordinary  abor- 
tion may  be  suspected.  Sometimes  vesicular  mole  is  mistaken 
for  a  uterine  neoplasm.  When,  after  hemorrhages,  expulsion  does 
not  take  place  the  diagnosis  of  missed  abortion  may  be  made.  It 
is  interesting  to  note  that  true  hydatid  development  due  to  the 
echinococcus  may  very  rarely  be  found  in  iitero.  Their  nature 
is  made  evident  by  the  presence  of  echinococcus  heads  and 
hooklets. 

Treatment. — When  the  diagnosis  is  established  the  uterus 
should  be  emptied.  This  is  best  carried  out  as  follows  :  If  the 
cervix  is  patulous  it  and  the  vagina  should  be  firmly  tamponed 
and  the  patient  placed  in  bed.  When  the  cervix  is  closed  it  should 
be  partly  dilated  artificially  in  order  that  the  gauze  may  be  in- 
serted. If  after  twelve  or  fourteen  hours  the  mole  is  expelled  the 
patient  should  be  anesthetized  and  the  uterine  cavity  carefully  ex- 
plored with  one  or  two  fingers,  all  vesicles  remaining  in  it  being 
carefully  removed.  If  the  mole  be  not  expelled  by  uterine  efforts, 
dilatation  of  the  cervix  should  be  carried  out  and  the  mole  re- 
moved with  the  fingers.  After  the  uterus  is  emptied  the  cavity 
should  be  packed  with  gauze  for  twenty-four  hours.  It  is  inad- 
visable to  use  a  curet,  on  account  of  the  risk  of  perforating  the 
uterine  wall  at  some  thinned  portion. 

When  vesicles  are  firmly  united  to  the  uterine  wall  no  force 
should  be  employed  in  trying  to  detach  them.  It  is  best  to  re- 
move those  that  easily  come  away  and  to  curet  the  uterus  after  a 
week  or  two. 

Relation  of  Vesicular  Mole  to  Malignancy. — In  a  con- 
siderable number  of  cases  vesicular  mole  takes  on  a  malignant 
type  of  development.  This  will  be  described  under  the  heading 
Chorio-epithelioma  Malignum.  Findley  states  that  the  change 
occurs  in  about  16  per  cent,  of  all  cases.  He  states  that  no  sharp 
histologic  distinction  can  be  made  between  the  simple  and  malig- 
nant forms,  and  that  the  length  of  time  the  mole  remains  in  the 
uterus  bears  no  relation  to  the  tendency  to  become  malignant. 

In  all  cases  it  is  advisable  to  curet  the  uterus  a  couple  of  weeks 
after  it  has  been  emptied,  in  order  to  make  a  microscopic  exami- 
nation of  the  tissues.  Only  in  this  way  is  it  possible  to  detect 
malignant  transformation  in  its  earliest  stages.  If  at  any  period 
during  the  succeeding  three  years  uterine  hemorrhage  should 
occur,  curettage  and  microscopic  examination  of  the  tissues  should 
be  carried  out. 

Myxoma  DifFusum. — Very  rarely  a  mucoid  hypertrophy 
may  be   found  in  that  portion  of  the  chorion  from  which  the  villi 


350  DISEASES   OF  THE    OVUM. 

spring.     It  may  be  spread  over  a  large  area,  forming  a  gelatinous 
layer  under  the  amnion  3  to  5  mm.  thick. 

Myxoma  Fibrosum. — Occasionally  a  fibroid  thickening  of 
the  chorion  is  found  either  in  the  subamniotic  layer  or  in  the  villi. 
It  is  found  usually  in  advanced  pregnancy. 

PLACENTA. 

Anomalies. — At  term  the  shed-placenta  is  a  rounded  disk 
weighing  about  a  pound.  Its  average  diameter  is  about  7  in. ;  its 
thickness  varies  from  |  to  i  in.,  being  greatest  near  the  middle. 
In  some  cases  the  thickness  is  fairly  even  in  all  parts  ;  in  others  it 
varies  considerably  in  different  parts.  There  may  be  marked 
fissuring  in  some  cases  and  a  complete  absence  in  others.  The 
size  of  the  placenta  also  varies  considerably,  the  largest  develop- 
ment being  found  in  uniovular  twin  cases. 

There  are  many  variations  as  regards  shape.  Thus,  it  may  be 
rounded,  oval,  ovoid,  reniform,  crescentic,  and  regularly  or  irregu- 
larly lobed.  One  or  more  detached  portions  may  exist  {^  place )Ua 
succe?itiiriatd).  The  latter  may  be  related  to  maternal  blood  just 
as  the  main  part  of  the  placenta.  Rarely  the  detached  portion 
may  be  as  large  as  that  to  which  the  cord  is  attached,  explaining 
what  is  sometimes  described  as  a  double  placenta  with  a  single 
fetus.  In  such  a  condition  the  cord  may  end  m  the  membranes 
between  the  placental  portions,  its  vessels  going  to  each.  Some- 
times the  villi  of  the  detached  mass  are  functionless  ;  to  such  a 
mass  the  term  "  placenta  spuria  "  has  been  applied. 

Very  rarely  the  placenta  may  extend  around  the  uterus  in  a 
ring-like  manner,  similar  to  the  condition  found  in  some  mam- 
malia. Sometimes  it  has  a  gap  in  its  substance  { placenta /enes- 
trata).  The  cord  may  have  a  central,  lateral,  or  marginal  insertion. 
In  the  latter  condition  the  arrangement  has  often  been  compared 
to  the  shape  of  a  battledore.  Rarely  the  cord  may  be  inserted  into 
the  membranes,  its  vessels  running  in  the  chorion  to  the  placenta. 

Myxomatous  Degeneration.— This  change  has  already 
been  described  in  connection  with  hydatidiform  changes  in  the 
chorion.  The  effect  on  the  fetus  depends  mainly  on  the  amount 
of  change  in  the  villi. 

Calcareous  Deposits. — Occasionally  small  portions  of  cal- 
careous material  are  found  on  the  maternal  surface  of  the  placenta. 
They  may  be  in  the  decidua  attached  to  the  ends  of  the  villi, 
or  sometimes  in  the  substance  of  the  latter  ;  their  causation  is 
unknown. 

Bdema. — The  placenta  is  sometimes  swollen  and  edematous. 
The  causes  are  probably  both  maternal  and  fetal,  but  are  not  well 
understood.  It  has  been  several  times  noted  in  connection  with, 
obstructive  conditions  in  fetal  circulation. 


FIBROUS  DEGENERATION  OF   THE   PLACENTA. 


351 


Fibrous  Degeneration. — This  change  in  the  stroma  of  the 
chorionic  membrane  and  villi  is  a  very  common  one  in  the  ad- 
vanced stages  of  normal  pregnancy,  and  there  is  no  evidence  that 


Fig.  140. — Portion  of  placenta  with  diffuse  fibrous  thickening  of  chorionic  layer. 
I.  Fetal  surface  with  amnion  removed.  II.  Section  through  thickness  of  above  portion, 
a,  Branches  of  umbilical  vessels ;  b,  thickened  chorionic  layer ;  c,  normal  placental 
tissue. 


it  is  an  indication  of  a  diseased  process.  The  delicate  mucoid 
stroma  of  the  early  weeks  gradually  changes  into  a  dense  struct- 
ure, in  many  parts   resembling  connective-tissue  sclerosis.     There 


352  DISEASES    OF   THE    OVUM. 

is  a  relatively  large  quantity  of  the  matrix  in  proportion  to  the 
nuclei.  Many  cells  are  shrivelled  and  lie  in  spaces.  In  many  of 
the  vessels  great  thickening  of  the  intima  is  found.  Remains  of 
the  early  mucoid  tissues  may  usually  be  found  only  in  some  of 
the  small  (latest-formed)  villi.  In  many  of  the  villi  attached  to 
the  decidua  the  disappearance  of  the  covering  epithelium  may 
make  the  connective  tissue  of  the  stroma  appear  to  be  continuous 
with  that  of  the  decidua,  and  it  may  be  difficult  in  some  instances 
to  distinguish  between  them. 

Fatty  Degeneration. — This  has  been  described  as  occurring 
when  the  nutrition  of  the  villi  is  interfered  with,  frequently  in  con- 
nection with  fibrous  changes  in  the  villi,  and  following  death  of 
the  fetus  where  the  placenta  is  not  immediately  expelled. 

Inflammation. — The  relation  of  the  placenta  to  inflammation 
is  not  at  all  well  understood.  Much  of  the  published  work  deal- 
ing with  diseased  conditions  is  worthless,  because  it  was  written 
when  the  true  nature  of  the  normal  placenta  was  not  understood. 
As   regards    the    maternal   decidua    to   which   the   fetal   villi   are 


i^-^ 


*^**; 


' 


Fig.  141. — Section  across  a  placenta  extensively  atrophied  and  degenerated.  Seventli 
month  of  pregnancy  :  a,  Unaltered  portion  of  placenta;  h,  portion  greatly  atrophied 
and  degenerated ;  c,  portion  partly  atrophied  and  degenerated ;  d,  membranes. 
(Reduced.) 

attached,  there  is  no  doubt  that  occasionally  it  may  be  affected 
along  with  the  rest  of  the  mucosa  in  an  inflammatory  process 
often  termed  "  deciduitis."  That  the  change  may  spread  to  the 
attached  villi  is  possible.  As  to  inflammation  in  the  main  tissue 
of  the  placenta,  which  is  entirely  of  fetal  origin,  we  know  little. 
Frankel  has  shown  that  such  a  process  is  not  infrequent  in 
syphilis.  He  has  described  the  infiltration  of  villi  with  inflam- 
matory products,  resulting  in  hypertrophies  and  distortions. 

Syphilis. — While  the  influence  of  syphilis  in  its  various  forms 
on  the  life  of  the  ovum  has  been  well  described  from  the  clinical 
point  of  view,  we  are  as  yet  in  want  of  correspondingly  accurate 
data  regarding  the  pathologic  changes  accompanying  its  different 
manifestations.  This  is  largely  due  to  the  rarity  of  specimens  of 
the  pregnant  uterus  removed  from  syphilitic  women.  The  ovum 
alone  is  often  enough  obtained,  but  no  complete  account  of  the 
pathology  can  be  given  until  the  condition  of  the  uterus  has  been 
carefully  studied.  It  is  of  extreme  importance  to  ascertain  whether 
the  vessels  and  other  tissues  of  the  maternal  mucosa  are  affected 
in  all  forms  of  the  disease  or  only  in  certain  cases  ;  whether  local 


PLACENTAL    INFARCTS.  353 

maternal  changes  are  necessarily  preliminary  to  fetal  changes ; 
which  of  the  fetal  structures  are  most  prone  to  be  affected,  and 
what  are  the  variations  related  to  the  different  kinds  of  syphilitic 
infection.  At  present  it  is  sufficient  to  state  that  inflammatory 
changes  and  gummatous  formations  have  been  described  in  the 
decidual  tissue  ;  endarteritis  has  also  been  noted.  In  the  chorionic 
membrane  and  villi,  chronic  thickening  due  to  inflammatory 
products  may  easily  be  demonstrated.  Infarcts  in  the  placenta 
are  common.  When  numerous  and  of  old  standing  they  lead  to 
the  destruction  of  many  portions  of  the  placenta,  which  are  recog- 
nized as  whitish  or  yellowish,  firm  areas.  Thrombosis  may  also 
occur  in  the  intervillous  space,  the  thrombi,  when  of  old  standing, 
becoming  organized,  the  resulting  fibrous  tissue  compressing  and 
destroying  many  villi. 

Cysts. — These  are  occasionally  found,  especially  near  the 
fetal  surface  of  the  placenta.  Some  are  beheved  to  arise  from  a 
localized  myxomatous  degeneration  of  the  chorion ;  others,  from 
the  degeneration  of  infarcts  and  hemorrhages. 

Tumors. — Myxomatous  and  fibromyxomatous  swellings  have 
already  been  noted.  Occasionally  a  single  large  swelling  occurs, 
of  combined  fibrous  and  myxomatous  nature.  Sometimes  the 
swelling  may  consist  mainly  of  angiomatous  tissue,  the  tumor 
being  termed  fibromyxoma  telangiectodes.  These  forms  probably 
arise  in  the  chorion.  Albert  has  collected  a  number  of  these 
cases,  and  has  pointed  out  the  frequency  of  abnormalities  in  con- 
nection with  the  pregnancy — /.  e.,  hydramnios,  hemorrhages,  and 
premature  emptying  of  the  uterus.  Certain  tumors  described  as 
fibromata  are  probably  merely  organized  blood-clots  or  throm- 
boses. In  this  connection  deciduoma  malignum  may  be  mentioned, 
as  the  new  growth  usually  develops  in  connection  with  placental 
remains  ;  occasionally  the  disease  probably  begins  before  the  birth 
of  the  ovum. 

Tuberculosis. — The  effects  of  tuberculous  infection  on  the 
placenta  are  not  fully  known.  Local  lesions  have  been  noted  in 
the  decidua  and  in  the  chorion.  In  cases  in  which  the  mother 
presents  distinct  tuberculosis  elsewhere,  tubercle  bacilli  may  be 
found  in  the  fetal  tissues,  though  no  changes  may  exist  in  the 
placenta.  Lehmann,  however,  points  out  that  placental  lesions  may 
be  so  slight  as  to  be  easily  overlooked  ;  the  most  careful  micro- 
scopic examination  is  necessaiy.  Tubercle  bacilli  may  be  found 
in  them,  though  in  small  numbers.     (See  p.  87.) 

Placental  Infarcts  and  Apoplexies. — The  frequent  occur- 
rence of  localized  areas  of  pale,  dense  tissue  in  the  placenta  has 
been  noted  by  many  observers,  and  different  views  have  been 
advanced  to  explain  their  formation.  Perhaps  the  most  widely 
held  opinion  is  that  which  regards  them  as  due  to  hemorrhages 
in  the  placenta.  In  the  light  of  recent  work  it  would  appear  that 
2:5 


354  DISEASES   OF  THE    OVUM. 

this  explanation  is  not  correct.  Indeed,  true  apoplexies  or  local- 
ized extravasations  of  maternal  blood  are  very  rare. 

Williams,  one  of  the  most  recent  workers  in  this  subject,  sup- 
ports the  view,  originally  advanced  by  Ackermann,  that  the 
primary  cause  of  infarct  formation  is  to  be  found  in  a  thickenino- 
of  vessels  in  the  villi,  mainly  in  the  inner  wall.  As  a  result,  he 
states,  there  is  a  coagulation-necrosis  of  portions  of  the  villi  just 
beneath  the  syncytium,  with  subsequent  formation  of  canalized 
fibrin.  As  the  process  advances  the  syncytium  degenerates  and  is 
changed  into  canalized  fibrin.  This  is  followed  by  the  coagulation 
of  the  blood  in  the  intervillous  space,  which  results  in  the  matting 
together  of  groups  of  villi  oy  masses  of  fibrin.  In  the  advanced 
stages  the  stroma  of  the  villi  degenerates,  so  that  it  resembles  the 
fibrin  around  it.  While  Ackermann's  explanation  may  be  correct 
as  regards  the  development  of  many  infarcts,  it  is  probable  that  it 
does  not  apply  in  all  cases.  Degeneration  and  disappearance  of 
syncytium  occur  apart  from  primary  degeneration  in  the  stroma 
of  the  villus.  The  removal  of  the  anticoagulating  influence  of 
the  syncytium  may  thus  suffice  to  induce  fibrin  formation  in  the 
maternal  blood  in  localized  areas. 

Moderate  degrees  of  infarct  formation  are  not  to  be  regarded 
as  pathologic,  being  frequently  found  in  normal  cases,  but  are 
probabl)'  due  to  senile  changes  in  the  chorion.  There  is  no  doubt 
that  diminution  in  the  caliber  of  the  vessels  of  the  chorion  is  a 
normal  change  toward  the  end  of  pregnancy,  owing  to  thickening 
of  the  intima.  The  endothelium  is  swollen  in  some  parts  and 
proliferated  in  others,  while  often  an  appearance  like  hyaline  de- 
generation is  noted.  These  infarcts  are  for  the  most  part  white 
or  yellow  in  color ;  they  vary  in  size  from  small  dots  to  large 
portions  of  the  placenta.  They  may  be  found  next  the  amniotic 
surface  in  the  substance  of  the  placenta,  or  at  the  maternal  surface ; 
frequently  they  are  situated  at  the  edge.  Sometimes  they  are 
found  as  a  thick  band,  running  around  the  fetal  surface  at  some 
distance  from  the  edge.  In  the  latter  condition  the  placenta  is 
often  termed  placenta  uiarginata.  In  some  cases  this  ring-like 
band  is  found  half  an  inch  or  more  internal  to  the  edge.  Rarely 
pinkish  infarcts  are  noted,  and  still  more  rarely  bright-red  or  dark 
plum-colored  masses  are  found.  Occasionally  white  infarcts  are 
found,  termed  by  Eden  "  non-fibrinous."  These  are  an  agglom- 
eration of  villi  not  bound  together  with  fibrin.  Marked  infarct 
formation  may  be  noted  in  various  diseased  conditions  of  the 
mother,  particularly  where  there  is  albuminuria.  They  may  be 
found  in  syphilitic  cases,  though  they  are  not  particularly  charac- 
teristic of  this  condition. 


CONVOLUTION   OF   THE    UMBILICAL    CORD.  355 

UMBILICAL  CORD. 

Anomalies. — The  cord  presents  many  peculiarities  of  develop- 
ment. It  may  be  abnormally  long,  sometimes  measuring  5  or  6 
feet.  It  may  be  very  short,  being  only  4  or  5  in.  in  length  ;  the 
latter  condition  is  to  be  distinguished  from  relative  shortness,  an 
artificial  production  due  to  excess  of  convolutions  around  the 
fetus  or  to  adhesions  to  the  amnion  or  amniotic  bands. 

The  Whartonian  jelly  of  the  cord  may  be  very  irregularly 
distributed  ;  in  some  parts  it  may  be  almost  entirely  absent,  so 
that  the  diameter  of  the  cord  is  much  diminished.  Sometimes  the 
cord  may  contain  two  veins  and  one  artery  or  one  vein  and  one 
artery  ;  sometimes  two  cords  pass  to  one  placenta. 

Velamentous  Insertion. — The  cord  may  sometimes  not 
enter  the  placenta,  but  may  end  in  the  membranes  at  some  dis- 
tance from  its  edge,  the  vessels  separating  and  running  in  the 
chorion  to  the  villi.  The  condition  is  most  frequent  in  multiple 
pregnancy.  It  is  a  cause  of  danger  to  the  fetus  both  in  pregnancy 
and  labor.  Sometimes  it  may  lead  to  premature  rupture  of  the 
membranes.  It  is  a  predisposing  cause  of  prolapse  of  the  cord. 
Pressure  on  the  membranes  during  labor  may  bring  about  fetal 
death.  Rarely  the  vessels  may  be  ruptured.  Lefevre  believes 
that  the  anomaly  explains  some  cases  of  hydramnios  and  fetal 
dropsy. 

Torsion. — Different  arrangements  of  torsion  in  the  vessels 
have  already  been  described.  Some  variations  are  probably  natural, 
but  in  some  cases  marked  torsion  of  the  whole  cord  on  its  longi- 
tudinal axis  is  due  to  movements  of  the  fetus.  In  most  cases  the 
torsion  is  most  evident  near  the  fetus.  Occasionally  the  turns  are 
so  numerous  as  to  make  the  cord  resemble  a  coil  of  wire  spring. 
In  a  case  noted  by  Schauta  380  twists  were  counted.  Edema  and 
cystic  changes  have  been  found  with  marked  torsion.  Great  nar- 
rowing of  the  cord  and  partial  or  complete  obliteration  of  its 
vessels  may  also  be  brought  about. 

Convolution. — The  cord  may  be  arranged  in  various  ways  in 
relation  to  the  fetus.  Frequently  it  passes  from  the  umbilicus  over 
the  chest,  around  the  neck,  and  down  in  front  of  the  other 
shoulder.  Occasionally  it  is  coiled  once  or  several  times  around 
the  neck,  body,  or  limbs.  The  largest  number  of  turns  around 
the  body  yet  described  is  9.  Extra  convolutions  are  almost  always 
associated  with  abnormal  length  of  the  cord.  Division  of  the  soft 
tissues  of  the  neck  has  rarely  been  noted  as  the  result  of  coiling ; 
amputation  of  a  limb  has  been  more  frequently  described.  Direct 
strangulation  of  the  child  is  very  rare.  As  regards  labor,  Bruttan 
states  that  in  Dorpat,  where  convolution  of  the  cord  has  been  fre- 
quently observed,  stillborn  children  are  not  more  frequent  than  in 
cases  where  convolutions  arc  absent,  tliough  a  larger  percentage 


356  DISEASES    OF   THE    OVUM. 

are  born  more  or  less  asphyxiated ;  there  is  more  risk  of  pressure 
on  the  cord  in  primiparae.  The  greatest  risk  exists  where  there 
is  some  form  of  dystocia.  Excessive  convolution  may  cause  delay 
in  labor  when  the  free  portion  of  the  cord  is  thereby  made  very 
short. 

Knots  of  the  Cord. — Occasionally  the  cord  may  be  knotted 
as  a  result  of  the  movements  of  the  fetus  in  titero  during  preg- 
nancy ;  sometimes  it  may  occur  during  labor.  Generally  only  one 
knot  is  formed,  but  there  may  be  more.  In  the  case  of  twins  in  an 
amniotic  sac  there  may  be  marked  twisting  or  knotting  of  the 
cords.  In  the  great  majority  cf  instances  no  damage  to  the  fetus 
results  from  the  presence  of  these  knots,  since  they  are  usually 
loose.  Very  rarely  is  the  circulation  interfered  with.  The  Whar- 
tonian  jelly  may  be  displaced  where  the  folds  of  the  knots  cross 
when  the  latter  have  lasted  some  time.  Sometimes  a  condition  of 
the  cord  exists  to  which  the  term  "  false  knot  "  has  been  given,  to 
distinguish  it  from  the  above-described  "true  knot."  It  consists 
of  a  projection  along  the  course  of  the  cord,  due  to  a  localized 
accumulation  of  Whartonian  jelh'  or  to  a  sharp  bend  or  curve  in 
one  of  the  vessels. 

Changes  in  the  Vessels. — The  alterations  associated  with 
maternal  and  fetal  diseases  have  not  been  well  established. 
Winckel  and  Swiecicki  have  pointed  out  the  frequency  of  ex- 
cessive narrowing  of  the  vessels  from  changes  in  the  intima  and 
outer  wall  in  s}'philis,  heart  and  kidney  diseases  of  the  mother, 
and  in  other  affections.  The  vein  or  arteries  or  both  may  be 
affected.  Torsion  may  lead  to  a  partial  or  complete  stenosis  of 
the  vessels.  Varicose  enlargements  occasionally  occur ;  rupture 
has  been  described. 

Hernia. —  Sometimes  at  birth  the  fetal  abdominal  viscera  lie  in 
an  extension  of  the  celom  into  the  cord  ;  otherwise  the  fetus  may 
be  healthy.  Frequently  some  other  abnormality  exists — /.  c,  im- 
perforate anus,  malformations  of  the  outer  genitals,  etc.  The 
hernia  varies  in  size ;  it  may  contain  only  small  intestines,  but  in 
some  cases  large  intestine,  stomach,  liver,  and  other  viscera. 

Swellings  of  the  Cord. — These  are  rare.  Cysts  are  some- 
times found  ;  also  blood-effusions,  myxomata,  and  telangiectatic 
myxofibroma. 


PREMATURE   EXPULSION   OF   THE    UTERINE    CONTENTS.     35/ 


CHAPTER    XIII. 

PREMATURE    EXPULSION  OF  THE  UTERINE 
CONTENTS. 
Abortion ;  Miscarriage  ;  Premature  I/abor. — Definition. 

— By  many  the  term  abortion  is  applied  to  expulsion  of  the  ovum 
during  the  first  three  months ;  miscarriage,  to  expulsion  during 
the  second  three  months ;  premature  labor,  to  expulsion  during 
the  last  three  months.  Others  use  the  first  two  terms  synony- 
mously, referring  to  expulsion  of  the  ovum  before  viability  of  the 
fetus  ;  in  the  great  majority  of  cases  this  takes  place  in  the  twenty- 
eighth  week.     In  this  article  the  latter  definition  is  employed. 

Frequency. — No  accurate  statement  can  be  made  regarding 
the  frequency  of  premature  emptying  of  the  uterus.  Statistics 
given  by  different  authorities  vary  considerably.  Thirty-seven  per 
cent,  of  all  childbearing  women  are  said  to  abort  at  least  once 
before  the  age  of  thirty-one,  and  after  this  the  percentage  is  higher. 
Probably  many  very  early  pregnancies  terminate  without  being 
recognized  as  an  abortion,  the  attendant  hemorrhage  being  re- 
garded as  a  menstrual  disturbance.  Abortion  is  much  less  fre- 
quent during  the  first  than  during  succeeding  pregnancies.  The 
third  and  fourth  months  are  those  in  which  it  is  most  apt  to  take 
place.  Very  often  the  date  of  its  occurrence  is  that  corresponding 
to  a  menstrual  period. 

Etiology. — The  causes  of  abortion  are  very  numerous,  being 
all  conditions  that  set  up  uterine  action.  They  are  often  classified 
as  maternal,  fetal,  and  paternal ;  but  it  is  impossible  to  arrange 
them  into  distinct  divisions,  assigning  to  each  a  definite  form  of 
action.  In  many  cases  more  than  one  factor  is  in  operation,  and 
it  is  often  impossible  to  .state  which  is  the  most  important  deter- 
mining cause.  Thus,  there  are  many  maternal  conditions  in  which 
abortion  occurs,  in  which  the  causal  factors  may  be  a  high  febrile 
state,  poisons  circulating  in  the  blood,  which  may  cause  death  of 
the  fetus  ;  intra-uterine  hemorrhages,  causing  fetal  death  or  stimu- 
lating the  uterus  to  contraction. 

Speaking  generally  as  regards  the  mother,  conditions  that  are 
associated  with  high  temperature,  extreme  exhaustion,  nervous 
shock,  accumulation  of  poisons  in  the  blood,  hemorrhages  in  the 
decidua  or  in  the  attached  fetal  structures  or  which  lead  to  me- 
chanical interference  with  the  normal  development  of  the  pregnant 
uterus,  are  among  the  most  important  causes  leading  to  abortion. 
Among  the  conditions  are:  I.  The  acute  infectious  diseases, 
syphilis,  and  tuberculosis.  2.  Various  diseases  of  the  nervous, 
urinary,    circulatory,    respiratory,    and    alimentary    systems.       3. 


358     PREMATURE   EXPULSION   OF   THE    UTERINE    CONTENTS. 

Various  inflammations,  displacements,  and  neoplasms  of  the  uterus 
and  other  pelvic  structures.  4.  All  forms  of  mental  shock  and 
emotional  excitement.  5.  Traumatism — /.<?.,  dancing,  riding,  falls, 
passage  of  foreign  bodies  into  the  uterus,  etc. 

As  regards  the  ovum,  there  are  many  factors  that  lead  to 
abortion,  either  by  causing  death  of  the  fetus  or  by  stimulating  the 
uterine  muscle  directly.  Such  are  diseases  and  abnormalities  of 
the  chorion,  amnion,  or  cord  ;  hydramnios ;  sudden  escape  of 
liquor  amnii ;  diseases  or  malformations  of  the  fetus,  causing  death. 
The  paternal  influences  causing  abortion  are  not  well  understood. 
Syphilis  is  the  best  known.  Tuberculosis  and  some  other  condi- 
tions markedly  affecting  health  are  believed  in  some  cases  to  induce 
premature  emptying  of  the  uterus.  Advanced  age  or  extreme 
youth  is  thought  to  act  in  the  same  way. 


v.. 


Fig.  142. — Ovum  embedded  in  blood-clot  (Ahlfeld). 

Symptoms. — Signs  of  Abortion. — These  vary  greatly.  The 
chief  clinical  phenomena  are:  (i)  Pains  in  the  pelvis,  (2)  hemor- 
rhage, and  (3)  expulsion  of  part  or  the  whole  of  the  ovum  and 
decidual  tissue. 

In  some  cases  the  uterine  contents  may  be  expelled  suddenly 
without  the  previous  occurrence  of  any  of  the  above  symptoms. 
As  an  illustration  may  be  mentioned  the  case  of  a  woman  who 
passed  a  three  months'  ovum  while  in  the  middle  of  a  dance  in  a 
ball  room,  without  any  warning  whatever.  In  some  cases  pain  is 
entirely  absent ;  in  others  there  may  be  little  or  no  bleeding  before 
the  ovum  is  expelled.  Sometimes  only  blood-serum  escapes ; 
sometimes  the  liquor  amnii  first  gushes  out.  Very  frequently 
pain  is  felt  early  in  the  sacral  region  as  a  continuous  aching. 
Often    intermittent    labor-like    pains    are    present.      Fulness   and 


ABORTION;    MISCARRIAGE ;    PREMATURE    lABOR.        359 

weight  in  the  pelvis  and  frequency  of  micturition  may  be  noted. 
Bleeding  may  precede  pains,  may  be  noticed  synchronously,  or 
may  follow  them.  It  may  pass  in  driblets  or  as  a  profuse  flow  ; 
or  may  collect  in  the  vagina  and  form  large  clots.  The  blood 
may  be  retained  in  the  uterus,  distending  it  and  increasing  the 
pain.  Clotting  may  occur  in  the  cervix,  only  the  blood-serum 
escaping.  Sometimes  bleeding  takes  place  only  at  night,  when 
the  patient  lies  down,  ceasing  when  she  walks  about.  This  is 
probably  due  to  the  sinking  of  the  reflexa  and  ovum,  which  acts 
as  a  plug  to  the  internal  os  while  the  woman  is  in  the  erect 
posture. 

The  duration  of  an  abortion  varies  greatly.  As  stated  above, 
it  may  take  place  in  a  very  few  minutes,  so  far  as  the  woman's 
subjective  knowledge  is  concerned ;  ordinarily  it  lasts  over  a 
period  of  several  hours.  In  some  cases  the  phenomena  may 
extend  over  several  days,  being  more  or  less  constant  or  inter- 
mittent in  character.  When  the  ovum  is  not  entirely  expelled 
certain  effects  may  be  produced  that  may  be  evident  months  or 
years  afterward.  On  physical  examination  in  the  early  stages  of 
abortion  the  enlarged  uterus  may  be  palpated.  When  pregnancy 
is  advanced  only  two  or  three  weeks  it  is  impossible  to  be  certain 
as  to  the  nature  of  the  enlargement.  Usually  variations  in  its 
consistence — alternate  hardening  and  softening — may  be  distin- 
guished. Very  early  no  dilatation  of  the  cervix  may  be  felt,  even 
though  blood  may  be  escaping  from  it.  Later  it  is  more  or  less 
patulous,  so  that  a  finger  may  readily  be  introduced,  and  present- 
ing portions  of  decidua,  ovum  or -blood-clot  be  felt. 

Mechanism  of  Abortion. — Berry  Hart  has  pointed  out  that  in 
many  cases  in  which  a  complete  abortion  is  expelled  we  may  have 
a  definite  mechanism,  which  he  terms  "  normal."  Of  this  there 
are  two  varieties  :  First,  that  in  which  expansion  of  the  lower 
uterine  segment  is  accompanied  by  a  separation  of  the  decidua 
vera,  the  whole  abortion  mass  consisting,  from  below  upward,  of 
the  outer  portion  of  the  vera  and  serotina,  reflexa,  and  contained 
ovum ;  second,  that  in  which,  as  the  vera  gets  separated,  the 
reflexa  and  superficial  part  of  the  serotina  with  the  contained 
ovum  are  driven  down  into  the  cervix,  the  vera  following  after- 
ward as  the  abortion  procee/ds.  As  regards  the  separation  plane 
in  the  case  of  a  complete  abortion,  my  researches  show  that  it 
passes  mainly  through  the  compact  layer  of  the  serotina  and  vera 
in  the  middle  or  outer  part ;  in  certain  areas  the  whole  compact 
layer  and  bits  of  the  spongy  may  be  shed.  It  is  exceptional  to 
find  any  considerable  quantity  of  the  latter  removed.  Probably 
the  majority  of  abortions  do  not  take  place  in  either  of  these 
manners  ;  very  often  the  uterine  contents  come  away  in  successive 
portions,  the  expulsion  often  being  only  partial.  In  these  abnor- 
mal  cases   sometimes   everything    may  escape  except  the   vera. 


360    PREMATURE  EXPULSION  OF   THE    UTERINE    CONTENTS. 

The  reflexa,  along  with  the  superficial  part  of  the  serotina  and 
the  contained  ovum,  may  easily  be  mistaken  for  a  complete  abor- 
tion on  careless  examination.  In  other  cases  parts  only  of  the 
vera  may  be  left,  or  again  parts  or  the  whole  of  the  serotina  may 
be  left  along  with  attached  villi  and  with  more  or  less  of  the 
reflexa. 

Sometimes  the  reflexa  may  be  broken  off  at  its  junction  with 
the  serotina  and  expelled  with  or  without  the  amniotic  sac  and  its 
contents.  Sometimes  the  fetus  alone  or  the  entire  ovum  may  be 
expelled  through  the  reflexa,  the  decidual  structures  being  ex- 
pelled partly  or  entirely  at  a  later  date.  Occasionally  the  entire 
amnion  and  its  contents  may  alone  be  expelled.  Very  frequently 
saprophytes  invade  the  retained  tissues,  leading  to  a  foul-smelling 
discharge,  fever,  chills,  etc. ;  at  the  same  time  septic  infection  may 


Fig.  143. — Fleshy  mole  (after  Fothergill)  :  a,  Amniotic  surface;  b,  uterine  surface. 

also  occur.  In  some  cases  fibrinous  deposits  may  accumulate  on 
the  remains  of  the  ovum,  forming  a  large  intra-uterine  polypus  ; 
this  may  also  become  infected.  In  cases  of  long  retention  of  por- 
tions of  the  ovum  in  the  uterus,  changes  similar  to  those  to  be 
described  in  connection  with  Missed  Abortion  take  place  in  the 
tissues. 

Varieties. — Different  terms  are  employed  to  describe  the  vari- 
ous stages  in  which  abortions  are  met  with  clinically. 

Threatened  Abortion. — This  condition  is  one  in  which  there  are 
sym.ptoms  pointing  to  the  commencement  of  expulsion  of  the 
uterine  contents  ;  as  already  indicated,  these  vary  in  different  cases. 
Ordinarily  there  are  pelvic  pains,  with  or  without  hemorrhage  and 
with  little  or  no  dilatation  of  the  cervix.  In  many  cases  of  early 
pregnancy  the  threatening  occurs  at  the  time  corresponding  to  a 
menstrual  period. 


ABORTION;   MISCARRIAGE  ;   PREMATURE   LABOR.        36 1 

Inevitable  Abortio?i. — This  is  the  condition  in  which  the  threat- 
ening symptoms  have  become  more  marked  and  persistent,  so 
that  all  hope  of  preventing  the  abortion  must  be  given  up.  In 
this  stage  usually  the  cervix  is  dilated,  so  that  a  finger  may  be 
introduced.  Often,  however,  it  cannot  be  passed  through  the  in- 
ternal OS.    Expulsion  of  portions  of  the  decidua  vera  is  generally 


V  . 


B 


Fig.  144. — Complete  abortion  about  twenty-fourth  day  of  pregnancy  :  A.  Outer 
surface  of  decidua  vera,  with  an  opening  at  site  of  os  internum.  B.  The  same  opened, 
showing  prominence  of  decidua  reflexa  containing  ovum.  C.  Portion  of  decidua 
reflexa  with  chorion  lasve  dissected  from  amnion.  D.  Portion  of  amnion  removed, 
showing  embryo  in  the  amniotic  cavity. 


regarded  as  a  sign  of  inevitable  abortion ;  but  this  is  not  always 
the  case,  for  occasionally  this  may  take  place  in  a  threatening 
abortion,  and  yet  pregnancy  continue  afterward. 

Complete  Abortion. — This  is  the  condition  in  which  everything 
that  should  be  expelled  escapes  from  the  uterus.  The  constituents 
of  the  complete  abortion  have  already  been  described. 

Incomplete  Abortion. — In  this  condition  there  are  left  in  the 


362     PREMATURE   EXPULSION   OF   THE    UTERINE    CONTENTS. 

Uterus  decidual  tissue,  fetal  structures,  or  parts  of  both.  The 
variations  that  occur  have  been  noted  above. 

Habitual  Abortion. — This  term  is  applied  to  the  repeated  occur- 
rence of  abortion  in  the  same  woman.  In  some  instances  preg- 
nancy may  be  interrupted  successively  at  the  same  period  ;  in 
other  cases,  however,  the  time  is  variable. 

Missed  Abortion. — Occasionally  a  fetus  may  die  in  ntcro  and 
no  abortion  occur ;  in  some  cases  no  threatening  even  taking 
place  at  the  time  of  fetal  death.  The  uterus  may  retain  its  con- 
tents for  weeks,  months,  or  sometimes  for  years.  This  may  happen 
in  twin  as  well  as  in  single  pregnancy.  Sometimes  both  ova, 
sometimes  only  one,  may  perish  ;  the  latter  may  occur  even  when 
two  fetuses  lie  in  one  amniotic  cavity.  The  appearance  of  the 
uterine  contents  when  expulsion  finally  does  occur  varies  con- 
siderably in  different  cases.  Sometimes  the  fetus  is  preserved  in 
a  shrivelled  condition,  wrapped  up  in  the  membranes  and  placenta, 
the  liquor  amnii  having  been  absorbed  or  previously  expelled ; 
the  term  "  blighted  ovum  "  is  applied  to  this  condition.  In  other 
instances  the  ovum  and  decidual  tissues  are  largely  altered  by 
hemorrhagic  effusions,  forming  a  mass  termed  the  carneous,  fleshy, 
or  sarcous  mole,  or  molar  abortion.  The  fetus  may  be  entirely  or 
partially  absorbed  ;  sometimes  only  a  small  part  of  the  umbilical 
cord  may  be  recognized.  The  villi  in  these  masses  are  found  in 
various  stages  of  degeneration,  similar  to  those  already  described 
in  placental  infarcts ;  the  maternal  blood  may  be  found  in  all 
stages,  from  the  recently  effused  red  clot  to  the  well-advanced, 
organized,  pale  fibrin  mass.  The  term  fibrous  mole  is  applied  to 
the  mass  when  the  connective  tissue  of  the  villi  is  changed  to 
dense,  wavy,  fibrous  tissue,  with  few  corpuscular  elements.  Berrj' 
Hart  has  recently  described  such  a  mole  that  had  remained  in 
ntcro  nine  months,  the  threatening  of  abortion  having  occurred  in 
the  third  month  of  gestation.  The  mole  was  a  white,  glistening 
mass,  with  a  small  amniotic  cavity  at  one  end,  but  with  no  fetus  ; 
it  was  composed  almost  entirely  of  fibrous  villi  massed  together. 
In  places  where  the  villi  did  not  touch,  the  epithelium  covering 
them  was  partially  preserved ;  many  well-marked  decidual  cells 
were  found.  In  some  early  abortions  may  be  noticed  hemor- 
rhagic effusions  in  the  decidua  and  chorion,  forming  bulgings 
inward  toward  the  amniotic  cavity.  To  this  condition  Breus  has 
given  the  name  of  tuberose  subcJiorio7iic  Jiematoma  of  the  decidua. 
He  holds  that  death  of  the  embryo  precedes  the  development  of 
the  hematomata,  the  amnion  and  chorion  continuing  to  develop, 
being  thrown  into  folds  that  become  filled  with  blood.  Neumann 
has  criticised  Breus's  views,  rightly  holding  that  he  is  mistaken  in 
believing  that  the  amnion  and  chorion  grow  after  the  death  of  the 
embryo ;  he  urges  that  the  condition  described  by  Breus  is  merely 
a  form  of  the  fleshy  mole,  the  protuberances  being  caused  by 


ABORTION;    MISCARRIAGE;    PREMATURE   LABOR. 


363 


irregular  extravasations  under  the  chorion.  Berry  Hart  states 
that  there  is  undue  blocking  of  the  serotinal  sinuses,  leading  to  a 
slow  engorgement  of  the  intervillous  circulation.  Blood-swellings 
thus  form,  thrombosis  gradually  developing.  The  embryo  dies 
as  the  result  of  this  interference  with  the  intervillous  circulation. 
.  The  clinical  history  in  these  cases  of  missed  abortion  varies. 
Usually  after  a  period  of  amenorrhea,  during  which  various  signs 
and  symptoms  of  pregnancy  may  be  present,  there  are  hemorrhage 
from  the  uterus  and  perhaps  some  other  signs  of  abortion  (often 
believed  by  the  patient  to  be  an  actual  abortion) ;  afterward  another 
period  of  amenorrhea,  lasting  for  weeks  or  months,  until  the  mass 
is  expelled  from  the  uterus.     Instead  of  a  second  period  of  amen- 


FlG.  145. — Tuberose  subchorionic  hematoma  of  decidua :  a.  Amniotic  surface  of 
early  abortion  sac  ;  b,  embryo  ;  c,  large  blood-clot  in  decidua,  forming  a  bulging  in 
amniotic  cavity  ;  d,  d,  d ,  small  blood-clots. 


orrhea  there  may  be  irregular  discharges  of  blood ;  sometimes 
there  is  no  hemorrhage  at  all.  Occasionally  putrefactive  changes 
may  occur  and  a  fetid  discharge  result ;  sometimes  septic  infec- 
tion may  occur.  During  this  latter  period  the  uterus  may  diminish 
somewhat  in  size,  thereafter  remaining  in  a  stationary  degree  of 
enlargement,  or  it  may  become  slowly  and  progressively  larger 
owing  to  a  succession  of  fresh  hemorrhages  in  the  ovum. 

The  length  of  time  that  a  missed  abortion  may  remain  in  the 
uterus  is  not  definitely  known  and  accurate  observations  are  want- 
ing. Resnikow  has  reported  a  case  in  which  a  febrile  attack  in  a 
woman  seven  months  pregnant  destroyed   the   life  of  the  fetus. 


364     PREMATURE  EXPULSION  OF  THE    UTERINE    CONTENTS, 

Labor  pains  came  on  for  a  short  time,  followed  later  by  a  purulent 
discharge  and  rigors  ;  amenorrhea  then  succeeded.  After  four 
years  the  uterus  was  dilated  and  the  bones  of  a  seven  months' 
fetus  removed.  Sometimes  in  such  cases  a  communication  may 
be  established  between  the  uterus  and  the  rectum,  through  which 
some  of  the  fetal  bones  may  escape.  Landucci  has  reported  such 
an  occurrence.  The  subject  is  of  considerable  importance  from 
the  medicolegal  point  of  view,  as  was  recently  shown  in  a  well- 
known  trial  in  London.  On  February  23,  1894,  a  physician  re- 
moved from  a  woman  a  piece  of  tissue  left  after  an  abortion  that  was 
regarded  by  him  as  of  recent  origin.  The  woman  maintained  that 
it  was  a  portion  of  the  product  of  a  conception  that  had  occurred 
at  least  eighteen  months  previously,  being  part  of  a  blighted  ovum 
retained  in  the  uterus  from  October,  1892,  when  the  threatening 
of  an  abortion  had  occurred,  resulting  in  the  death  of  the  fetus. 

No  difficulty  should  exist  in  the  determination  of  the  probable 
age  of  an  abortion.  If  the  chorionic  tissue  be  of  recent  origin, 
well-formed  villi  with  preserved  epithelium  can  be  made  out, 
whereas  in  missed  abortion  of  some  duration  characteristic  altera- 
tions can  be  made  out.  These  are  gradual  disappearances  of  the 
fetal  epithelium,  amniotic  and  chorionic  ;  fibrin  formation  in  the 
blood  of  the  intervillous  spaces  ;  and  gradual  invasion  of  the  fibrin 
by  connective  tissue  of  decidual  type.  Fothergill  believes  that 
these  decidual  cells  gradually  absorb  the  fibrin  and  the  remains  of 
epithelial  cells,  and  that  thus  the  connective-tissue  cores  of  the 
villi  tend  to  be  surrounded  by  decidual  tissue,  the  whole  forming 
a  firm  mass.  To  it  Hartman  and  Toupet  have  applied  the  name 
"  decidiiouia  benigjiuin."  Sometimes  calcification  may  take  place 
in  the  villi. 

Prognosis. — Loss  of  the  mother's  life  rarely  accompanies  spon- 
taneous abortion.  Yet  a  fatal  result  may  sometimes  take  place 
from  hemorrhage  or  rupture  of  the  uterus  ;  sometimes  it  may 
be  due  to  an  acute  or  chronic  infective  process.  Deciduoma 
malignum  may  develop  in  connection  with  an  abortion,  causing 
death. 

In  many  cases  results  follow  that  do  not  prove  fatal,  but  lead 
to  much  ill  health.  These  are  mainly  associated  with  incomplete 
abortion,  which  may  lead  to  protracted  loss  of  blood,  to  the  de- 
velopment of  a  fibrinous  polypus,  to  subinvolution  of  the  uterus 
with  hypertrophied  and  congested  mucosa,  and  in  cases  of  infec- 
tion to  various  forms  of  pelvic  and  systemic  disturbances.  Com- 
plete abortion  may  be  followed  by  ill  health,  due  to  great  loss  of 
blood  or  to  the  results  of  septic  infection.  A  rapid  succession  of 
abortions  usually  leads  to  deterioration  of  the  system  from  one 
or  more  of  the  above  causes.  Many  women  injure  themselves  by 
regarding  an  abortion  as  a  matter  of  no  importance.  They  either 
refuse  to  cease  from  ordinary  routine  of  their  life,  or  if  they  go  to 


ABORTION;   MISCARRIAGE ;   PREMATURE   LABOR.        365 

bed,  rise  too  soon  and  work  too  early.  As  a  consequence,  pro- 
tracted weakness,  subinvolution,  displacements,  etc.,  are  apt  to 
result.  In  criminal  abortion  the  risks  to  the  mother  are  enor- 
mously increased  owing  to  the  unskilful  use  of  instruments,  to  the 
lack  of  aseptic  measures,  or,  when  drugs  are  employed,  to  their 
destructive  effects  on  the  system. 

Differential  Diagnosis. — There  are  difficulties  of  diagnosis  in 
connection  with  the  different  varieties  of  abortion.  A  threatening 
abortion  may  simulate  a  number  of  conditions,  and  vice  versa. 
The  most  important  point  in  making  a  diagnosis  is  to  determine 
whether  or  not  pregnancy  exists.  To  do  this  is  often  impossible, 
especially  in  the  early  weeks.  Consequently  there  is  often  much 
uncertainty  in  diagnosing  abortion.  In  women  who  have  irregular 
menstruation,  a  flow  of  blood  coming  on  after  several  weeks  of 
amenorrhea  may  be  mistaken  for  abortion.  The  error  is  more 
easily  made  when  the  flow  is  accompanied  with  uterine  pains  of  a 
labor-like  character.  The  case  may  be  more  complicated  when 
there  is  some  uterine  enlargement,  such  as  may  be  due  to  inflam- 
mation or  new  growth  of  the  uterus  and  when  some  of  the  reflex 
signs  and  symptoms  of  pregnancy  are  present.  Sometimes  there 
may  be  pelvic  pain  and  loss  of  blood,  due  to  some  condition  out- 
side of  the  uterus  altogether — i.  c.,  vaginal  new  growths,  hemor- 
rhoids, etc.  Haultain  has  described  an  interesting  case  in  which  a 
clot  in  the  bladder  caused  dilatation  of  the  sphincter  urethrae,thus 
allowing  blood  to  escape,  a  threatening  abortion  being  closely 
simulated.  A  uterine  hemorrhage  occurring  in  the  course  of  an 
ectopic  pregnancy  is  often  mistaken  for  an  abortion,  sometimes 
with  serious  results.  In  some  cases  of  pregnancy  there  is  in  the 
early  months  an  escape  of  blood  from  the  uterus  before  the  space 
between  the  reflexa  and  vera  is  obliterated  ;  it  may  occur  in  suc- 
cessive gestations  in  the  same  woman.  Usually  such  a  case  is 
regarded  as  a  threatened  abortion. 

The  fact  of  threatened  abortion  being  established,  it  is  often 
difficult  to  decide  whether  or  not  it  is  inevitable.  If  the  bleeding 
be  profuse,  or  if  under  treatment  it  ceases  and  begins  again ;  if 
uterine  contractions  are  frequent  and  strong  and  continue  in  spite 
of  treatment ;  if  the  cervix  be  dilated  so  that  a  finger  may  feel 
parts  of  the  ovum  or  decidua  bulging  into  the  cervical  canal ;  if 
the  amniotic  cavity  be  ruptured  or  the  fetus  be  dead,  the  abortion 
must  be  regarded  as  inevitable  in  the  great  majority  of  cases. 
Occasionally,  however,  the  physician  makes  a  mistake  and  is 
surprised  to  find  that  abortion  does  not  occur,  even  though  the 
symptoms  have  been  so  marked  as  to  lead  him  to  believe  it  inevi- 
table. Cases  have  been  recorded  in  which  even  the  amniotic 
cavity  has  been  ruptured  and  yet  pregnancy  has  continued  to  full 
time.  With  regard  to  the  condition  of  the  fetus,  it  is  to  be  noted 
that  in  the  first  three  or  four  months  it  is  impossible  to  know  when 


366     PREMATURE   EXPULSION   OF   THE    UTERINE    CONTENTS. 

it  has  died.  Usually  this  occurrence  is  soon  followed  by  emptying 
of  the  uterus,  but  in  a  few  cases  this  does  not  follow,  and  it  is  then 
found  that  there  is  gradual  disappearance  of  the  various  reflex 
sympathetic  symptoms  and  signs  of  pregnancy. 

In  the  early  months  the  latter  may  be  very  slight  in  certain 
cases,  and  their  disappearance  may,  therefore,  be  unrecognizable. 
When  an  abortion  has  occurred  it  is  very  important  to  decide 
whether  it  has  been  complete  or  incomplete.  It  is  possible  to  give 
a  positive  diagnosis  only  when  the  physician  is  able  to  examine 
what  has  been  passed  from  the  uterus  ;  in  the  great  majority  of 
cases  he  is  unable  to  do  this.  If  he  cannot  decide  in  this  way,  he 
may  gain  information  either  by  examining  the  interior  of  the 
organ  under  anesthesia  or  by  watching  the  clinical  phenomena  for 
some  time  after  the  abortion.  The  first  method  is  satisfactory  in 
a  certain  measure,  but  it  is  impossible  to  be  accurate,  especially 
with  regard  to  determining  whether  or  not  the  decidual  tissue  has 
separated.  In  all  cases  of  doubt  the  uterus  should  be  curetted 
if  the  operation  can  be  properly  carried  out.  The  second  method 
is  fairly  satisfactory,  though  it  subjects  the  patient  to  risks.  If  an 
abortion  be  incomplete,  the  uterus  does  not  remain  as  firm  and 
small  as  after  complete  expulsion  ;  the  lochial  discharge  is  usually 
more  profuse,  the  loss  of  blood  more  marked,  remaining  con- 
tinuous or  intermittent  for  days  and  weeks,  and  the  patient's  health 
depressed. 

A  complete  abortion  may  itself  be  easily  mistaken  for  other 
conditions,  and  7'ice  versa.  Thus,  a  period  of  amenorrhea  fol- 
lowed by  a  profuse  loss  of  blood,  wdiich  may  continue  intermit- 
tently afterward  with  excessive  leukorrhea  and  general  weakness, 
maybe  due  to  inflammator)^  conditions  of  the  uterus,  retroversion, 
mucous  or  fibroid  poh'pi,  or  other  conditions.  Sometimes  these 
diseased  states  may  reflexly  set  up  some  of  the  well-known  signs 
and  symptoms  of  pregnancy.  When  a  fibrinous  polypus  has 
formed  after  an  incomplete  abortion,  it  may  easily  be  mistaken  for 
a  true  neoplasm,  simple  or  malignant.  When  putrefactive  changes 
take  place  in  the  remains  of  an  incomplete  abortion,  the  signs  and 
symptoms  may  closely  simulate  those  of  malignant  disease  or  of 
a  sloughing  fibroid. 

Missed  abortion  may  often  be  very  difficult  to  diagnose.  Some- 
times it  is  regarded  as  a  second  pregnancy,  an  abortion  having 
been  thought  to  occur  when  only  a  threatening  has  taken  place. 
Generally  the  pregnancy  is  regarded  as  continuing  satisfactorily 
following  upon  a  threatened  interruption.  The  observation  of  a 
fe\y  weeks,  however,  shows  that  the  uterus  is  not  developing  in  a 
normal  manner.  In  some  cases  the  diagnosis  of  new  growth 
of  the  uterus  is  made.  This  is  particularly  apt  to  be  the  case  if 
hemorrhacfes  occur,  if  the  fineer  introduced  into  the  cervix  feels 


ABORTION^-    MISCARRIAGE ;    PREMATURE   LABOR.        367 

a  mass  in  the  cavity,  or  if  putrefaction  has  begun,  leading-  to  a 
foul-smelling  discharge  from  the  uterus. 

Treatment. — Prophylactic. — When  a  woman  has  aborted  once 
or  several  times,  the  most  careful  examination  should  be  made 
and  treatment  carried  out  before  she  becomes  pregnant  again. 
If  her  health  be  much  run  down,  an  effort  should  be  made  to 
restore  it.  If  there  be  a  syphilitic  taint,  the  parents  should  be 
subjected  to  a  long  course  of  antisyphilitic  remedies  before  preg- 
nancy is  allowed  to  occur  again.  Diseased  conditions  in  the 
pelvis  should  be  treated.  Thus,  a  retroverted  uterus  may  require 
to  be  replaced  and  supported  by  a  pessary.  Sometimes  the  re- 
moval of  adhesions  by  operation  may  be  necessary.  A  tumor 
may  require  to  be  taken  away.  If  there  be  chronic  inflammation 
in  the  uterus,  it  should  be  reduced.  After  an  abortion  has  oc- 
curred, at  least  eight  months  (in  the  syphilitic  cases  much  longer) 
should  elapse  before  pregnancy  is  allowed  to  take  place  again. 

When  the  woman  falls  pregnant  she  must  take  particular  care 
of  herself,  avoiding  excitement  and  fatigue  and  paying  attention 
to  the  digestive  tract.  She  should  rest  in  bed  during  the  times 
corresponding  to  menstrual  periods,  not  rising  even  to  urinate  or 
defecate. 

Coitus  during  pregnancy  should  be  prohibited,  especially  in 
the  first  half.  Purgatives  should  be  avoided.  Iron  and  other 
tonics  need  be  given  only  when  the  system  requires  them.  The 
administration  of  potassium  chlorate,  as  recommended  by  Simp- 
son, is  thought  by  many  to  exercise  a  beneficial  influence.  The 
correction  of  pelvic  disorders  may  be  necessary. 

/;/  Threatened  Abortion. — The  patient  must  be  kept  absolutely 
at  rest  in  bed.  For  defecation  and  urination  a  bedpan  should  be 
used.  If  the  bowels  do  not  move  naturally,  laxatives  should  not 
be  given  ;  it  is  best  that  the  bowels  remain  quiet  for  a  few  days. 
The  diet  should  be  simple,  light,  and  non-stimulating.  Opium  or 
morphin  should  be  administered.  At  first,  if  uterine  contractions 
are  marked,  a  hypodermic  injection  of  the  latter  (^  gr.)  may  be 
given,  followed  in  four  hours  by  a  rectal  suppository  (^  gr.).  This 
may  be  repeated  every  four  or  five  hours  until  uterine  contrac- 
tions are  quieted  ;  then  the  quantity  may  be  cautiously  dimin- 
ished. In  some  cases  the  drug  may  be  continued  several  days. 
Viburnum  prunifolium  (liquid  extract)  given  by  the  mouth  in 
half-dram  or  dram  doses  every  six  or  eight  hours  is  used  by 
many  physicians  as  an  accessory  to  the  morphin.  Chloral  and 
bromids  are  also  used.  Cocain  rectal  suppositories  are  recom- 
mended by  MacVie.  To  obtain  a  movement  of  the  bowels  a 
glycerin  and  olive  oil  enema  should  be  used. 

When  the  treatment  is  satisfactory,  the  pains  and  hemorrhage 
gradually  disappear.  The  woman  should  not  then  be  allowed  to 
rise,  but  should  be  kept  at  rest  a  week  or  more.     When  she  gets 


368     PREMATURE  EXPULSION  OF   THE    UTERINE    CONTENTS. 

up  she  should  be  very  careful  to  avoid  all  strain,  fatigue,  excite- 
ment, and  worry,  and  should  lie  down  in  the  middle  of  the  day 
for  an  hour  or  two  during  the  succeeding  iow  weeks.  At  the 
succeeding  periods  corresponding  to  her  menstruation  she  should 
spend  a  few  days  in  bed. 

1)1  Inevitable  Abortion. — There  is  some  difference  of  opinion  as 
to  the  best  method  of  conducting  such  an  abortion  case.  Should 
nature  be  allowed  to  act,  or  should  artificial  means  always  be 
adopted  ?  There  is  no  doubt  that  artificial  cleaning  out  of  the 
uterus  under  proper  aseptic  precautions  is  a  most  satisfactory 
procedure,  but  it  is  best  not  to  employ  this  method  unless  condi- 
tions are  suitable  to  a  perfect  technic.  Very  often  the  patient  will 
not  allow  it  to  be  employed.  The  carelessness  on  the  part  of 
women  in  regard  to  the  conduct  of  abortion  is  much  to  be  depre- 
cated ;  on  the  part  of  the  physician  it  is  unpardonable.  The 
recklessness  with  which  many  practitioners  carry  out  surgical 
interference  without  any  regard  to  asepsis  is  the  cause  of  much 
calamity. 

In  a  number  of  cases  the  uterus  may  entirely  empty  itself  if 
the  patient  be  left  at  rest  in  bed,  and  no  interference  may  be  neces- 
sary. If,  however,  it  be  feared  that  the  vagina  is  not  aseptic  by 
reason  of  digital  examination,  recent  coitus,  or  some  diseased 
condition,  it  is  best  to  make  use  of  antiseptic  agents  in  order  to 
prevent  infection.  These  may  be  applied  in  the  form  of  frequent 
antiseptic  vaginal  douches.  In  cases  in  which  hemorrhage  is 
excessive  it  is  best,  after  cleansing  the  vagina,  to  tampon  the  latter 
firmly  with  antiseptic  or  aseptic  gauze.  In  cases  also  in  which 
the  abortion  proceeds  slowly  a  tampon  is  advisable  :  it  acts  both 
as  a  stimulant  to  uterine  contraction  and  as  a  mechanical  obstruc- 
tion to  bleeding.  It  must  be  noted  that  in  pregnancies  later  than 
the  fourth  month  bleeding  may  go  on  ///  iitero  in  some  cases  even 
though  a  firm  vaginal  tampon  be  in  position.  To  avoid  this  it  is 
well  to  allow  the  liquor  amnii  to  escape  by  puncturing  the  amnion, 
and  then  to  introduce  the  gauze  into  the  uterus  before  tamponing 
the  vagina.  The  plug  may  be  removed  in  ten  or  twelve  hours, 
when  the  complete  abortion  mass  may  often  be  found  in  the 
vagina.  If  this  is  not  the  case,  another  tampon  may  be  introduced 
for  twelve  hours  longer.  If,  however,  the  uterus  be  not  emptied, 
the  patient  may  be  anesthetized,  and  the  mass  removed  with  fingers 
and  curet.  A  hot  intra-uterine  douche  is  then  given  and  the 
patient  kept  at  rest  for  ten  or  twelve  days.  Many  advise  the  use 
of  ergot  in  order  to  promote  expulsion  and  to  check  hemorrhage. 
In  the  author's  opinion  this  is  an  unnecessary  procedure.  In 
diminishing  the  hemorrhage  of  abortion  it  is  not  so  satisfactory 
as  the  vaginal  tampon,  and  the  large  doses  necessary  are  very  apt 
to  contract  the  uterus  to  such  an  extent  that  the  os  internum  will 
not  allow  the  uterine  contents  to  pass  through   easily.     If  the 


ABORTION ;   MISCARRIAGE  ;    PREMATURE   LABOR.        369 

drug-  be  used  at  all,  it  should  be  given  in  small  doses  to  improve 
the  tone  of  the  uterine  musculature,  in  cases  in  which  it  acts 
feebly,  without  producing  violent  contraction.  Quinin  is  also 
recommended  for  this  purpose. 

In  Complete  Abortion. — When  the  uterus  has  spontaneously 
emptied  itself,  the  patient  should  be  kept  in  bed  and  treated  as 
though  normal  labor  had  occurred  ;  she  should  not  be  allowed  to 
rise  before  the  tenth  day.  If  there  is  reason  to  suspect  that  the 
vagina  is  not  sterile,  warm  antiseptic  vaginal  douches  should  be 
given  twice  daily  for  at  least  a  week.  When  much  blood  has  been 
lost  or  the  uterus  does  not  contract  well,  ergot  may  be  given  for  a 
few  days.  Intra-uterine  douching  is  necessary  only  when  blood- 
clots  tend  to  accumulate  above  the  os  internum  or  when  there  is 
evidence  of  intra-uterine  infection  ;  it  should  be  carried  out  only 
by  means  of  a  double  catheter.  Sometimes  so  profuse  a  hemor- 
rhage may  occur  after  a  complete  abortion  as  to  require  an  intra- 
uterine or  a  vaginal  tampon  for  twenty-four  hours  or  more. 

In  Incomplete  Abortion. — ^The  ordinary  practice  of  administer- 
ing ergot  when  the  uterus  is  incompletely  emptied  cannot  be  too 
highly  condemned.  Though  bleeding  may  be  checked  for  a  time, 
the  woman  is  left  in  a  condition  very  favorable  to  the  development 
of  after-troubles — i.  e.,  recurrent  hemorrhage,  subinvolution,  and 
acute  or  chronic  infective  processes.  An  incomplete  abortion 
mass  is  a  foreign  body  that  should  be  removed  from  the  uterus. 
There  is  some  difference  of  opinion  as  to  whether  this  should 
apply  to  a  non-separated  and  retained  decidua  vera.  As  nature's 
method  in  spontaneous  abortion  produces  exfoliation  and  delivery 
of  the  superficial  vera,  discussion  is  surely  needless.  There  is  no 
doubt  that  retention  of  a  considerable  portion  of  the  vera  may 
lead  to  after-troubles  in  many  cases — i.  e.,  congestion  and  sub- 
involution. 

Removal  of  the  uterine  contents  should  be  carried  out  as  a 
surgical  operation,  with  the  strictest  attention  to  technic.  The 
patient  should  be  anesthetized  and  placed  in  the  lithotomy  posi- 
tion. The  vulva  and  vagina  should  be  thoroughly  cleansed,  the 
bladder  and  rectum  having  been  emptied.  The  cervix,  held  by  a 
volsella,  should  be  dilated  with  a  series  of  graduated  dilators  until 
one  or  two  fingers  can  be  introduced  into  the  cavity  of  the  uterus. 
The  other  hand  presses  down  the  uterus  through  the  abdominal 
wall  while  the  intra-uterine  fingers  explore  the  cavity,  separating 
the  abortion  remains  from  the  wall.  These  portions  may  be  re- 
moved in  some  cases  by  the  fingers  ;  when  this  is  impossible,  the 
curet  forceps  may  be  employed.  Small  shreds  may  be  washed 
out  with  a  stream  of  water.  When  it  is  impossible  to  separate 
all  the  tissue  from  the  wall  with  the  fingers,  a  curet  forceps  and  a 
curet  may  then  be  employed.  In  some  cases  in  which  the  cervix 
contracts  even  after  dilatation  has  been  carried  out  these  instru- 

24 


370  ECLAMPSIA. 

ments  alone  can  be  used.  In  the  fifth  or  sixth  month,  when  the 
fetus  is  of  considerable  size,  if  contraction  of  the  cervix  is  very- 
marked,  it  is  best  to  dilate  as  much  as  possible  and  then  to  intro- 
duce a  Barnes  bag.  After  twelve  or  fourteen  hours,  if  the  abor- 
tion has  not  occurred,  the  uterus  may  then  be  more  easily  emptied. 
The  after-treatment  is  the  same  as  that  already  described. 

/;/  Missed  Abortion. — When  this  condition  is  diagnosed,  the 
uterus  should  be  emptied.  Sometimes  the  vaginal  tampon  may 
stimulate  the  uterus  to  contraction.  In  other  cases  the  intro- 
duction of  a  tampon  or  Barnes  bag  into  the  cervix  for  a  few  hours 
may  be  necessary.  Sometimes  dilatation  may  be  carried  out  so 
that  the  uterine  contents  may  be  removed  by  fingers,  curet,  and 
curet  forceps.  In  every  instance  the  uterus  should  be  carefully 
explored  to  insure  that  nothing  be  left  behind. 


CHAPTER    XIV. 

ECLAMPSIA. 

Eclampsia  is  an  acute  convulsive  attack,  characterized  in  a 
typical  case  by  tonic  and  clonic  muscular  contractions  and  loss 
of  consciousness.  The  disease  may  begin  in  pregnancy,  labor,  or 
the  puerperium. 

Frequency. — It  is  difficult  to  form  a  correct  estimate  of  the 
frequency  of  eclampsia.  Veit  and  others  give  a  general  propor- 
tion of  I  in  500;  Parvin,  i  in  333,  for  the  United  States;  and 
Corson,  i  in  300.  The  percentage  is  greater  in  hospital  than  in 
private  practice,  because  these  complicated  cases  are  so  frequently 
sent  to  institutions.  Lohlein,  in  1891,  gathered  statistics  from  30 
German,  Austrian,  and  Swiss  hospitals,  and  found  a  proportion  of 
I  in  161,  or  325  cases  in  52,328  labors.  Newell  reports  79  cases 
in  6700  labors,  or  i  in  84.8.  Veit,  in  1896,  found  a  proportion  of 
I  in  166,  or  905  cases  in  149,366  labors.  Charpentier,  among 
258,969  labors  in  France,  found  731  cases  of  eclampsia,  or  i  in 
354.  Schreiber,  among  42,609  labors  in  Vienna,  found  137,  or 
I  in  311. 

Great  variations  may  be  found  in  different  parts  of  the  same 
country.  Schmitt  has  published  the  following  statistics  regarding 
various  lying-in  institutions : 

Place.                                                                     Years.  Ratio. 

Berlin  (Universitats-Frauenklinik) 1877-85  i   in       49 

Berlin  (Charite) 1882-83  I   in       91 

"             " 1874-79  I   in  246 

Konigsberg 1874-77  i   ''^  261 

Dresden 1873-78  i   in  275 

Munich 1859-79  i   in  522 

Tubingen 1869-90  i   in  1697 


FREQUENCY.  3/1 

The  figures  for  Tubingen  are  remarkably  low.  Von  Saxinger, 
in  that  town,  had  not  a  single  case  in  his  clinic  during  twelve 
years. 

Some  authors  have  pointed  out  a  tendency  to  the  occurrence 
of  eclampsia  at  special  periods.  Olshausen,  in  five  and  a  half 
years'  experience  in  Berlin,  noted  that  the  cases  occurred  espe- 
cially between  September  and  February,  sometimes  being  so  close 
together  as  to  be  termed  epidemic.  Schroeder  held  that  damp 
weather  might  determine  an  outbreak.  Other  authors,  however, 
deny  that  there  is  any  epidemic  tendency. 

Eclampsia  is  more  frequent  in  primiparae.  The  percentage 
among  them  has  been  given  by  Lohlein  at  85.4,  by  Schauta  at 
82.6,  by  Braun  at  86.3,  by  Olshausen  at  74,  and  by  Newell  72.2. 
Goldberg  states  that  in  10,705  cases  of  labor  collected  by  Leopold, 
of  which  5363  were  primiparae  and  5342  multiparse,  eclampsia 
occurred  in  1.32  per  cent,  of  the  former  and  in  0.21  per  cent,  of 
the  latter.  Geuer  reports  5000  labors  in  the  Cologne  Maternity, 
among  which  50  cases  of  eclampsia  occurred ;  of  these,  42  were 
primiparae.  In  Schreiber's  137  cases,  100,  or  79.5  per  cent.,  were 
primiparae. 

It  is  generally  stated  that  a  considerable  percentage  of  eclamp- 
sia cases  is  found  in  very  young  primiparae — /.  e.,  in  those  under 
twenty — and  in  those  over  thirty.  Thus,  Diihrssen  reports  195 
cases  in  which  the  eclampsia  occurred  in  those  below  twenty 
and  in  those  over  thirty  in  40.5  per  cent.  ;  Zweifel  reports  a  per- 
centage of  25.  In  Olshausen's  cases  25  per  cent,  were  primiparae 
over  twenty-eight. 

In  most  cases  eclampsia  develops  during  labor,  and  there  is  a 
slightly  lower  percentage  in  the  puerperium  than  in  pregnancy. 
The  following  statistics  may  be  quoted : 

Pregnancy. 

Schroeder 20  per  cent. 

Braun  .......  28        " 

Winckel 23        " 

Olshausen 40        " 

Diihrssen 27.5     " 

Goldberg 25.9    " 

Geuer 12        " 

Schreiber 16.78  " 

Green's  statistics  during  eight  years'  experience  at  the  Boston 
Lying-in  Hospital  were  as  follows : 

Maternal  mortality.  Fetal  mortality. 

Eclampsia  before  labor 46  per  cent.  69  per  cent. 

"  during     " 25        "  25        " 

"  after        "      ........     7        " 

In  Schreiber's  137  collected  cases  the   maternal   mortality  of 


Labor. 

Puerperium. 

60  per  cent. 

20  per  cent 

53       " 
60       " 

19 

17 

46       " 
48.5    " 
57-14" 

14 

24        " 

16.8    " 

74       " 
62.04  " 

14 
21.16  " 

372  ECLAMPSIA. 

cases  commencing  before  labor  was  30.43  per  cent. ;  during  labor, 
18.82  per  cent. ;  after  labor,  13.79  P^^  cent. 

Diihrssen  gives  the  following  analysis  of  his  195  cases  : 

Eclampsia.  Primiparse.  Multiparae. 

Before  labor 25  6 

Before  and  during  labor 13  2 

Before  and  after  labor 6  o 

Before,  during,  and  after  labor 3  o 

During  and  after  labor 40  7 

During  labor 41  5 

After  labor 35  12 

Totals 163  32 

It  is  interesting  to  note  how  frequently  the  disease  develops 
among  primiparse  during  labor.  As  regards  the  occurrence  of 
eclampsia  in  pregnancy,  it  is  to  be  noted  that  it  is  most  frequent 
in  the  late  months.  It  has,  however,  been  observed  as  early  as 
the  fourth  month  b)'  Willis.  Tarnier  gives  the  following  statistics 
of  52  cases : 


I  case    at  5  months. 
5  cases  at  6       " 
4  "     7        " 


Bar's  statistics  of  48  cases  are : 

2  cases  at  6  months. 
I  case    at  b\     " 
8  cases  at  7       " 

7z 


14  cases  at  8  months. 
5  "     8A     " 

16  "     9"     " 


10  cases  at  8  months. 
4  "     8       " 

20  "     9       " 


As  regards  the  puerperium,  eclampsia  very  rarely  develops 
after  the  fourth  day — generally  within  a  few  hours  of  labor. 

Recurrence. — A  small  percentage  of  women  are  affected 
more  than  once  in  a  series  of  pregnancies.  In  Leopold's  81  cases 
it  occurred  more  than  once  in  2.5  per  cent. ;  in  i  case  it  developed 
in  3  successive  pregnancies.  In  Olshausen's  cases  it  occurred  in 
I  per  cent.  There  may  sometimes  be  an  interval  of  one  or  more 
normal  labors. 

Symptomatology. — In  a  number  of  cases  eclampsia  develops 
suddenly,  when  the  woman  is  apparently  in  a  good  state  of  health. 
Frequently,  however,  there  are  prodromal  or  pre-eclamptic  phe- 
nomena. These  vary  considerably  in  different  cases.  Very  often 
severe  headache  is  present,  generally  in  the  suboccipital  region. 
There  may  be  neuralgic  pains  in  one  or  more  terminal  branches 
of  the  sensory  cranial  nerves,  amaurosis,  color-blindness,  photo- 
phobia, diplopia,  strabismus ;  deafness,  increased  acuteness  of 
hearing,  ringing  and  buzzing  in  the  ears  ;  occasionally  there  are 
disturbances  of  general  sensation — /'.  c,  hyperesthesia,  anesthesia, 
formication,  and  ting-lincf.     Disturbed  brain  functions  are  some- 


SYMPTOMATOLOGY.  373 

times  found — /.  e.,  sleepiness,  stupor,  insomnia,  mental  confusion 
or  excitement,  and  despondency.  Sometimes  an  attack  is  pre- 
ceded by  terrifying  dreams,  nightmare,  and  restlessness  during 
sleep.      Rarely  there  is  a  dread  of  impending  trouble. 

Pain  and  distress  in  the  epigastrium  are  frequent,  and  may  be 
accompanied  by  nausea  and  vomiting.  Constipation  is  not  infre- 
quent, but  diarrhea  may  sometimes  exist.  In  some  cases  dyspnea 
is  a  prominent  feature  ;  it  is  usually  aggravated  by  the  slightest 
exertion.  The  temperature  is  generally  normal.  Albumin  is 
frequently  present  in  variable  quantities  in  the  urine ;  sometimes 
it  may  increase  considerably  just  before  the  attack.  The  urea 
may  be  deficient  or  the  quantity  of  urine  may  be  below  normal. 
Edema  is  found  in  a  considerable  number  of  cases. 

These  signs  and  symptoms  occur  in  great  variations,  and  they 
may  be  found  during  hours,  days,  or  weeks  preceding  an  attack. 
When  some  of  these  phenomena  are  found  in  a  pregnant  woman, 
eclampsia  does  not  necessarily  follow.  Their  presence  should, 
however,  always  be  regarded  as  a  warning  and  should  lead  to 
careful  examination  and  treatment  of  the  woman. 

The  eclamptic  attack  occurs  after  a  variety  of  conditions ;  it 
may  come  on  after  sleep  or  after  a  period  of  quiet  living.  Some- 
times it  may  follow  exercise,  emotional  excitement,  or  depression, 
change  of  diet  from  simple  to  indigestible  food,  etc.  It  is  very 
often  impossible  to  establish  with  accuracy  a  causal  connection 
between  the  attack  and  an  event  that  preceded  it.  Very  rarely 
there  may  be  an  aura  or  warning  that  an  attack  is  coming ;  it 
may  be  motor,  sensory,  or  psychic.  In  a  typical  eclamptic 
seizure  three  stages  may  be  described : 

1.  Stage  of  Invasion. — Fine,  rapid  choreic  movements  are 
seen  in  the  facial  muscles.  The  eyelids  move  quickly  and 
the  eyeballs  roll  up  and  down.  The  alae  nasi  and  mouth  are 
moved  convulsively,  the  latter  often  being  twisted  to  one  side. 
The  pupils  may  contract  and  then  dilate,  becoming  insensible  to 
light.  Almost  immediately  similar  movements  may  be  noticed  in 
other  parts,  especially  in  the  arms.  The  fingers  are  frequently 
clenched  and  the  forearms  pronated.  The  abdominal  muscles  are 
rarely  affected.  The  face  becomes  cyanosed.  This  stage  rarely 
lasts  longer  than  a  minute. 

2.  Stage  of  Tonic  Convulsions. — The  face  becomes  fixed,  the 
jaws  firmly  shut,  resulting  often  in  injury  to  the  tongue.  (Injury 
to  the  tongue  may  be  accompanied  by  septic  infection.  In  a  io-ys! 
cases  tetanus  infection  has  occurred.)  The  neck  may  be  bent 
back  and  the  back  markedly  curved.  The  arms  become  extended 
and  stiff,  the  fists  being  firmly  clenched.  The  thighs  may  be 
flexed  on  the  body.  The  muscles  of  respiration  are  affected,  the 
glottis  being  closed  and  the  chest  more  or  less  fixed,  and  breathing 
may  be  suspended  for  a  short  time,  or  there  may  be  one  or  two 


374  ECLAMPSIA. 

spasmodic  respirations.  There  is  some  asphyxiation.  Loss  of 
sensation  and  consciousness  is  generally  complete.  This  stage 
lasts  only  a  few  seconds. 

3.  Stage  of  Clonic  Spasms. — Clonic  movements  rapidly  super- 
vene after  the  tonic  convulsions,  often  following  a  long  respiration. 
They  begin  in  the  face  and  spread  to  the  neck,  arms,  and  other 
parts.  The  face  may  be  markedly  distorted  and  congested  ;  the 
eyelids  and  jaws  open  and  close  rapidly.  Blood  and  saliva  flow 
from  the  mouth.  This  stage  may  last  a  few  seconds  or  one  or 
two  minutes  ;  sometimes  it  may  be  prolonged.  Tarnier  has  re- 
ported it  as  lasting  twenty  minutes  in  one  case. 

In  many  cases  the  eclamptic  attack  does  not  follow  this  typical 
course.  All  degrees  of  movements  may  occur.  Sometimes  there 
may  be  very  slight  contraction  of  the  facial  muscles,  the  attack 
not  proceeding  beyond  a  few  of  the  phenomena  of  the  invasion 
stage.  In  some  cases  the  tonic  stage  is  veiy  short  and  scarcely 
perceptible,  clonic  movements  being  mainly  noticeable.  In  other 
cases  the  attack  may  be  unusually  prolonged  in  one  or  more 
of  the  stages — most  frequenth' that  of  clonic  contractions.  Some- 
times the  whole  attack  may  last  thirty  or  sixty  minutes.  Rarely 
only  one  attack  occurs.  When  there  are  .several,  they  suc- 
ceed one  another  at  intervals  of  var\-ing  length — seconds,  min- 
utes, or  hours.  Sometimes  a  period  of  one  or  more  days  may 
interv^ene. 

During  an  attack  the  pulse  is  small  in\'olume  and  rapid.  The 
arterial  tension  is  increased,  especially  during  the  height  of  tonic 
convulsions,  when  the  pulse  usualh'  becomes  irregular.  After 
the  attack  the  pulse  improves.  When  a  series  of  attacks  rapidly 
occur,  Ballant\'ne  has  shown  that  the  blood-pressure  lessens,  the 
pulse  becomes  dicrotic  and  very  rapid,  the  sphygmographic  curve 
resembling  that  found  in  acute  anemia.  During  an  attack  the 
temperature  usually  rises,  many  variations  being  found.  When 
attacks  are  frequent,  ending  fatally,  the  temperature  continues  to 
rise  to  104°  F.,  or  higher,  and  may  even  become  higher  after  death. 
In  some  cases  it  is  not  so  affected  by  frequency  or  intensity  of 
attack,  and  may  remain  stationary'  or  rise  \&ry  slightly.  In  some 
cases  where  the  attack  ceases  the  temperature  may  rise.  Occa- 
sional!}' a  fall  is  noted  before  death  occurs.  Sometimes  after  a 
considerable  rise  there  may  be  a  gradual  return  to  normal ;  this 
may  or  may  not  be  followed  by  fresh  attacks.  It  may  rise  after 
a  few  hours  to  a  high  point. 

When  eclampsia  occurs  during  pregnancy,  labor  usually  takes 
place  shortly  afterward.  In  some  cases  the  attack  is  coincident 
with  the  onset  of  definite  pains.  During  the  attacks  uterine  con- 
tractions continue  and  may  be  more  intense  and  rapid.  Labor 
sometimes  proceeds  very  quickly.  When  marked  tonic  contrac- 
tions affect  the  abdominal  muscles,  the  fetus  and  uterus  may  be 


DIAGNOSIS.  375 

markedly  pushed  downward.  The  uterus  probably  does  not  share 
in  the  convulsive  contractions.  The  ordinary  movements  of  the 
fetus  are  sometimes  intensified. 

Condition  of  the  Patient  after  an  Attack. — In  some 
cases,  where  there  are  very  slight  muscular  movements,  the  patient 
may  never  lose  consciousness  nor  feel  much  disturbed.  When  a 
well-marked  seizure  occurs,  consciousness  and  lucidity  may  some- 
times return  after  a  few  seconds ;  ordinarily,  however,  there  are 
lassitude  and  dulness.  Headache  may  be  marked.  There  may 
be  more  or  less  dimness  of  vision.  Frequently  there  is  a  semi- 
comatose condition,  during  which  the  patient  may  lie  quiet  unless 
she  be  disturbed,  when  she  may  attempt  to  mumble  incoherently 
or  to  move  without  purpose.  In  some  cases  there  is  profound 
coma  ;  rarely  this  is  followed  by  maniacal  symptoms. 

Occasionally  after  an  attack  the  patient  may  sleep  for  some  time, 
and  on  waking  may  not  know  what  has  happened,  even  though 
labor  may  have  been  completed.  In  some  cases  of  recovery  there 
may  be  a  continuance  of  the  above-mentioned  disturbances  for 
varying  periods  ;  sometimes  loss  of  memoiy  or  mental  derange- 
ment may  continue  indefinitely.  Occasionally  contractions  or 
paralyses  may  continue  as  the  result  of  damage  to  the  central 
nervous  system.  Pneumonia,  pleurisy,  gangrene  of  the  lung,  or 
sepsis  may  follow  eclampsia  ;  chronic  renal  disorder  may  continue. 

I^abor  in  i^clampsia. — Some  authors  state  that  labor  is 
always  shortened  by  the  eclamptic  attacks  ;  it  is  difficult  to  prove 
this.  The  disease  does  not,  at  least,  appear  to  lead  to  a  prolon- 
gation. Postpartum  hemorrhage  is  frequent,  mainly  due  to  uterine 
inertia ;  this  may  be  caused  by  excessive  anesthesia,  hurried  de- 
livery, or  lacerations.  Eclamptics  are  especially  liable  to  septic 
infection,  and  the  deHvery  must  be  conducted  with  the  strictest 
regard  to  asepsis. 

Diagnosis. — {a)  in  the  Pre=eclamptic  Stage. — The  various 
premonitory  phenomena  already  described  may  easily  be  misin- 
terpreted, especially  if  very  few  are  present  or  are  not  well  pro- 
nounced. The  warning  significance  of  mental  disturbance,  head- 
ache, neuralgia,  epigastric  pain,  anemia,  etc.,  may  thus  be  entirely 
overlooked. 

{F)  During  an  Eclamptic  Attack. — The  eclamptic  seizure  must 
be  distinguished  from  various  conditions.  It  may  be  mistaken  for 
hysteria,  but  in  this  disease  the  patient  is  rarely  unconscious  and 
does  not  injure  the  tongue.  There  is  often  marked  excitement. 
Convulsions  are  more  irregular  and  disordered.  There  is  an 
absence  of  well-marked  clonic  spasms.  The  patient  often  cries  or 
laughs,  and  the  attack  is  not  followed  by  coma.  Edema  or  albu- 
minuria is  not  present,  and  frequently  abundant  clear  urine  is 
passed.  There  may  be  a  history  of  previous  similar  attacks  in  the 
non-pregnant  state. 


■i^-jd  ECLAMPSIA. 

Epilepsy  is  distinguished  from  eclampsia  by  a  history  of  pre- 
vious attacks  and  by  the  absence  of  the  pre-eclamptic  phenomena. 
There  is  often  a  distinct  aura,  which  does  not  usually  precede  an 
eclamptic  attack.  The  invasion  stage  is  usually  more  severe  and 
sudden  in  epilepsy  ;  the  patient  usually  falls  suddenly  and  there  is 
often  an  initial  ciy,  whereas  in  eclampsia  the  latter  is  rare.  In 
epilepsy  the  temperature  is  not  raised  at  all  or  only  slightly. 
Edema  and  albuminuria  are  not  found  save  when  due  to  some 
associated  disease. 

Meningitis  may  simulate  eclampsia,  but  it  is  very  rare.  De- 
lirium is  apt  to  be  present ;  fever  precedes  the  convulsions,  which 
are  usually  more  localized  than  those  of  eclampsia  and  tend  to 
get  worse  only  gradually.  The  pulse  is  often  slow  when  the  tem- 
perature is  elevated. 

Brain  tumor  may  also  bear  certain  resemblances,  but  symptoms 
are  usually  preceded  by  a  gradual  histoiy,  and  often  there  are 
local  changes  due  to  pressure — e.g.,  optic  neuritis — sufficient  to 
establish  a  diagnosis. 

Cerebral  apoplexy  may  simulate  eclampsia,  but  it  is  very  rare 
in  pregnancy  ;  it  usually  begins  suddenly,  without  prodromata. 
Convulsions  are  rare  and  paralysis  is  evident.  It  must  be  remem- 
bered that  eclampsia  may  sometimes  be  complicated  by  cerebral 
hemorrhage,  and  the  diagnosis  is  generally  established  when 
paralysis  supervenes. 

ic)  In  the  Stage  of  Coma. — If  a  patient  be  first  seen  by  the 
physician  in  the  comatose  condition  following  the  convulsive  stage, 
the  case  might  be  mistaken  for  one  of  alcoholism.  It  might  be 
difficult  to  be  certain  unless  the  woman's  breath  indicated  that 
she  had  been  drinking.  Albumin  and  casts  would  not  likely  be 
present  in  her  urine  if  she  were  drunk. 

Post-eclamptic  stupor  might  easily  be  mistaken  for  cerebral 
concus.sion  or  cerebral  hemorrhage.  In  the  latter  condition 
paralysis  would  probably  be  present  and  the  temperature  low  if 
taken  early  in  the  hemorrhage ;  no  changes  would  be  expected  in 
the  urine.  Post-epileptic  stupor  simulates  post-eclamptic  stupor, 
but  is  of  short  duration  and  marked  by  little  or  no  rise  of  tem- 
perature, neither  are  there  changes  in  the  urine.  In  all  cases  of 
doubt  careful  examination  of  the  urine  should  be  made. 

Prognosis. — Eclampsia  is  a  very  serious  disease ;  the  maternal 
mortality  is  variously  estimated.  Judging  from  statistics,  it  has 
not  been  so  high  in  recent  as  in  former  years.  Thus,  Becquerel 
placed  it  at  50  per  cent.,  Pajot  at  46  per  cent.,  and  Brummerstadt 
at  37  per  cent.  In  Tarnier's  experience  it  was  30  per  cent. ;  in 
Olshausen's,  25  per  cent. ;  in  Diihrssen's,  21  percent.;  in  Pauper- 
toff's,  20.8  percent.;  in  Lohlein's,  23.7  per  cent.;  in  Leopold's, 
24.7  per  cent.  If  from  these  figures  be  deducted  the  cases  in 
which  death  resulted  from  compHcations,  the  percentage  would  be 


PROGNOSIS.  377 

slightly  reduced.  Thus,  Lohlein's  rate  would  be  diminished  to 
19.38  percent.;  DUhrssen's  to  19.8  percent.;  and  Leopold's  to 
29  per  cent. 

The  mortality  is  greater  in  multiparse  than  in  primiparae.  The 
following  statistics  are  given  : 

Observer.  Multiparae.  Primiparae. 

Lohlein 33.3  per  cent.  20.5  per  cent. 

Goldberg 45.4       "  21.4       " 

Diihrssen 28  "  19  " 

In  Lohlein's  325  cases  the  mortality  was  distributed  as  follows  : 

Primiparae.  Multiparae. 

Diseased.  Died.  Diseased.                      Died. 

In  pregnancy     ....     69  17  (24.3  per  cent. )              34  10  (29.4  per  cent. 

In  labor 115  18(15.7        "         )              31  7(22.6        "         ) 

After  labor 60  7(11-6        "        )              16  4(25.6        "         ) 

This  table  shows  the  highest  death-rate  to  be  among  multiparae 
in  pregnancy,  and  the  lowest  to  be  among  primiparae  during  the 
puerperium.  Tarnier  found,  however,  that  his  mortality  was  27 
per  cent,  during  labor,  31  per  cent,  during  pregnancy,  and  42  per 
cent,  in  the  puerperium.  In  pregnancy  the  prognosis  is  worse  the 
earlier  the  eclampsia  develops.  Of  the  cases  occurring  during 
parturition,  the  most  favorable  are  probably  those  in  which  the 
attack  develops  when  labor  is  well  advanced. 

As  regards  the  relationships  to  the  number  of  attacks,  it  ap- 
pears that  the  more  numerous  they  are,  the  greater  the  risk  of 
death.     Charpentier  has  published  the  following  statistics  : 

Number  of  attacks.  Mortality. 

I  to  10 25  per  cent. 

10  to  20 33        " 

21  to  50 50        " 

Schauta's  statistics  are  as  follows : 

Number  of  attacks.  Cases. 

10 152 

1 1  to  20 62 

21   to  30 24 

31  to  40 17 

41  to  50 5 

51  to  60 4 

Geuer  observed  in  a  study  of  12  cases  of  death  in  a  series  of 
50  cases  of  eclampsia  that  the  greatest  number  of  attacks  was  50 
and  the  smallest  4.  Among  the  38  cases  which  recovered  the 
greatest  number  of  attacks  was  17  and  the  smallest  i.  In  some 
cases  a  very  large  number  of  fits  may  be  observed.  Charpentier, 
Depaul,  and  Critcl  arc  reported  to  have  counted  more  than    150 


Number 
f  deaths. 

Mortality. 

36 

23.6  per  cent 

17 

27.4        " 

12 

50 

13 

76 

3 

60 

4 

100           " 

3/8  ECLAMPSIA. 

attacks  in  different  cases.  Such  cases  are  almost  always  fatal ; 
very  rarely  recovery  may  follow,  as  in  a  case  reported  by  Bailly 
and  Pajot,  in  which  there  were  more  than  lOO  fits.  Goldberg 
states  that  in  Leopold's  cases  the  attacks  numbered  from  8  to  24 
in  those  who  died.  The  average  for  all  cases  in  primiparae  was  7, 
and  in  multiparae  10  attacks. 

The  prognosis  must  indeed  always  be  grave  where  15  or  more 
fits  take  place.  It  must,  however,  be  remembered  that  death  may 
take  place  when  only  one  or  a  io-vf  attacks  are  noted.  The  more 
prolonged  the  fits,  especially  in  the  tonic  stage,  the  more  serious 
they  are.  Budin  states  that  the  prognosis  becomes  more  grave 
the  higher  the  temperature  rises.  The  more  profound  the  coma, 
the  worse  the  outlook.  Maniacal  symptoms  are,  very  unfavorable. 
Improvement  in  the  condition  of  the  pulse  between  the  attacks  is 
a  favorable  sign.  The  outlook  is  bad  when  it  continues  small, 
wiry,  and  frequent  or  irregular ;  as  long  as  it  is  full,  hard,  and 
regular,  even  though  frequent,  there  is  usually  no  immediate 
danger.  Extreme  dyspnea  is  unfavorable,  especially  if  pulmonary 
edema  be  present.  Anasarca  does  not  warrant  a  bad  prognosis 
unless  it  increases  rapidly  during  and  after  the  attacks. 

The  prognosis  is  unfavorable  when  the  urine  is  diminishing 
rapidly,  when  the  urea  is  very  scanty,  and  when  casts  and  albumin 
are  abundant.  Tarnier  and  Budin  state  that  icterus  with  high 
temperature,  scanty  and  blood-stained  urine,  and  subcutaneous 
ecchymoses  makes  the  prognosis  serious,  but  that  icterus  without 
the  other  signs  is  not  necessarily  grave.  Early  profuse  perspira- 
tion is  a  favorable  sign.  If  the  fetus  dies  early  in  the  attacks,  the 
prospects  of  recovery  are  greater. 

The  prognosis  may  be  made  worse  by  delay  in  treatment  or 
by  injudicious  treatment.  Thus,  when  the  uterus  is  emptied  ex- 
cessive shock  and  marked  loss  of  blood  may  exercise  a  bad  influence 
on  the  case.  Moreover,  faulty  technic  is  very  liable  to  lead  to 
septic  infection.  In  many  cases  asphyxiation  plays  an  important 
part,  the  oxygenation  of  the  blood  being  diminished  as  a  result  of 
the  interference  with  breathing  caused  by  the  fixing  of  the  muscles 
of  respiration.  The  asphyxiation  is  Avorse  when  pulmonary  edema 
is  present  and  when  fat  embolism  occurs  in  the  lung  capillaries. 
The  respiratory  center  is  also  probably  affected  by  the  toxic 
matters  circulating  in  the  blood,  and  it  may  be  gradually  paralyzed. 
The  heart  muscle  may  become  paralyzed  as  a  result  of  direct 
poisoning  as  well  as  of  interference  with  the  function  of  the  lungs. 
Degeneration  of  the  blood  and  destructive  changes  in  various 
organs  are  important  factors.  Cerebral  congestion  and  edema 
may  tend  to  hasten  a  fatal  issue  in  some  cases,  while  in  others 
cerebral  hemorrhage  is  the  determining  cause.  In  some  cases  an 
acute  or  chronic  septic  infection  maybe  fatal.  Rarely  pneumonia, 
gangrene  of  the  lung,  and  other  conditions  may  cause  death. 


FETAL   MORTALITY— PATHOLOGY.  379 

Fetal  Mortality. ^The  fetal  death-rate  is  high,  different  sta- 
tistics being  given.  Tarnier  found  in  304  cases  a  percentage  of 
60;  Depaul,  in  132  cases,  48  per  cent. ;  Lohlein,  in  325  cases,  56 
per  cent. ;  Olshausen,  in  200  cases,  45  per  cent.  Schauta  states 
that  the  mortaUty  is  higher  in  multiparae  than  in  primiparse. 
Diihrssen,  in  an  analysis  of  fetal  deaths  in  reference  to  the 
period  of  pregnancy,  states  that  in  the  seventh  month  and 
earlier  the  mortality  is  100  per  cent.  He  found  that  in  14 
cases  in  the  eighth  month  it  was  93  per  cent. ;  in  1 3  cases  in  the 
ninth  month  it  was  54  per  cent. ;  in  90  cases  at  term,  37.8  per 
cent. 

Rarely  convulsions  may  appear  in  a  child  which  survives  labor, 
due  to  the  influence  of  toxic  material  absorbed  ///  utcro.  Kreuz- 
mann  has  recently  reported  a  case  of  albuminuria  in  a  mother 
who  developed  no  eclamptic  phenomena ;  the  child,  however,  had 
convulsions  thirty-six  hours  after  labor.  He  considered  that  the 
toxic  agents  had  been  absorbed  from  the  colostrum  that  the  child 
swallowed  when  suckling. 

The  causes  of  the  fetal  mortality  are  not  absolutely  determined  ; 
asphyxiation  may  be  an  important  factor.  During  the  periods  in 
which  the  maternal  blood  is  asphyxiated  on  account  of  the  in- 
terference with  respiration,  there  is  a  marked  diminution  in  the 
amount  of  oxygen  that  passes  from  the  maternal  to  the  fetal  blood. 
In  some  cases  placental  infarcts  are  abundant,  and  as  a  result  many 
viUi  are  rendered  functionless ;  these  may,  therefore,  greatly  in- 
terfere with  the  oxygenation  of  the  fetal  blood.  When  there  is  a 
high  maternal  temperature,  the  vitality  of  the  fetus  is  impaired. 
Prematurity  of  delivery  exercises  a  bad  influence  in  many  cases. 
The  poisons  circulating  in  the  maternal  blood  probably  play  a  very 
important  part  in  destroying  the  fetus.  In  some  cases  the  method 
of  treatment  is  responsible  for  death  of  the  fetus. 

Pathology. — A  great  many  changes  are  found  in  cases  of 
eclampsia.  So  numerous  and  variable  are  they  that  at  the  present 
time  it  is  impossible  to  be  certain  as  to  the  features  that  are  to  be 
considered  as  characteristic  of  the  disease. 

Urinary  System — The  association  of  albuminuria  and  edema 
with  eclampsia  has  been  noted  for  many  years.  In  recent  times 
special  attention  has  been  given  to  the  renal  changes  occurring  in 
some  cases  of  pregnancy  and  labor  where  eclampsia  is  absent, 
especially  in  primiparae,  leading  to  the  use  of  the  term  "  kidney  of 
pregnancy."  These  changes  and  their  relationship  to  nephritis 
have  already  been  considered  along  with  the  various  theories  as 
to  their  causation.  (See  "  Pathology  of  Pregnancy.")  The  occur- 
rence of  albuminuria  and  edema  in  pregnancy  and  labor,  and  even 
sometimes  of  uremic  coma,  apart  from  eclampsia,  has  also  been  de- 
scribed. The  relationship  of  these  conditions  to  eclampsia  cannot 
be  accurately  estimated.    They  may  be  present,  undoubtedly,  with- 


380  ECLAMPSIA. 

out  eclampsia,  but  they  occur  in  the  circumstances  in  which  the 
latter  is  most  frequent,  and  are  similar  to  the  conditions  found  in 
eclampsia.  Both  may  be  produced  by  the  same  influences  ;  only  in 
eclampsia  there  is  an  uncertain  additional  factor  that  precipitates 
the  convulsive  seizures.  Many  variations  are  found  in  the  urine 
in  eclampsia.  The  total  quantity  is  usually  diminished.  Albumin 
is  frequently  present  in  varying  amounts.  The  specific  gravity  is 
generally  high.  Red  and  white  blood-corpuscles,  degenerated 
epithelium,  and  all  kinds  of  casts  may  be  present.  The  excretion 
of  urea  is  less  during  the  fits,  as  a  rule,  though  the  percentage 
may  not  vary. 

In  Diihrssen's  196  cases  in  which  the  urine  was  examined  the 
following  conditions  existed  :  Albuminuria  in  189  cases  (96  per 
cent.),  abundant  albumin  in  174  cases  (92  per  cent.),  formed  ele- 
ments (casts,  epithelium,  etc.)  in  121  cases,  hemoglobinuria  in  4 
cases,  urobilin  in  i  case.  There  were  edema  of  the  tissues  in  113 
cases  and  other  evidences  of  kidney  disturbance  in  25  cases. 

Sugar  is  sometimes  found  in  the  urine  of  eclamptics,  but,  as 
Fehling  points  out,  this  is  probably  milk-sugar  in  most  cases, 
absorbed  from  the  breasts.  Acetone  is  sometimes  found,  and 
possibly  may  be  associated  with  death  of  the  fetus.  Olshausen 
found  albuminuria  in  97  per  cent,  of  cases,  and  it  was  abundant  in 
50  per  cent.  Leopold  found  it  in  90.79  per  cent.,  and  edema  in 
50  per  cent.  Goldberg  noted  that  the  serious  cases  were  asso- 
ciated with  abundant  albuminuria  ;  of  20  which  died,  it  was  marked 
in  17.  As  regards  the  relation  of  edema  to  fatality,  it  is  interesting 
to  note  Leopold's  findings.  This  complication  was  present  in  40 
cases.  It  was  severe  in  10  cases,  all  of  whom  recovered  ;  moderate 
in  17,  of  whom  5  died;  slight  in  13,  of  whom  5  died.  Carstairs 
Douglas  has  suggested  that  possibly  edema  is  a  safety-valve  for 
serous  exudation,  subcutaneous  outpouring  being  less  dangerous 
than  intracranial,  for  example.  It  is  interesting  to  note  Bartel's 
statement  regarding  uremia  in  patients  with  Bright's  disease.  He 
states  that  it  is  more  frequent,  relatively  and  absolutely,  among 
those  who  are  not  dropsical  than  among  those  who  are. 

The  changes  in  the  kidney  structure  are  very  variable  ;  in  some 
cases  no  alterations  can  be  distinguished.  In  37  cases  Olshausen 
found  acute  and  subacute  processes  in  22  ;  in  73  cases  Schmorl 
found  changes  in  72  ;  in  368  cases  Prutz  found  only  7  healthy 
kidneys.  Cloudy  swelling  and  fatty  degeneration  and  necrosis  of 
the  epithelium  were  mostly  observed,  especially  in  the  cortex. 
In  a  few  cases  there  was  interstitial  nephritis,  parenchymatous 
nephritis,  or  chronic  interstitial  changes.  Renal  hemorrhages  were 
few.  Fibrinous  and  hyaline  thrombi  were  occasionally  found  in 
the  glomeruli.  In  one  of  Olshausen's  cases  the  right  kidney  was 
very  small  and  cystic  and  its  ureter  very  thin  ;  in  another  the 
right  ureter  was  somewhat  dilated;  in  another  ureteric  dilatation 


Plate  io. 


Fig.  I. — Kidney  in  eclampsia.  Tlie  section  is  stained  with  neutral  red  and 
osmic  acid,  showing  granular  and  fatty  degeneration  of  the  convoluted  tubules 
(R.  H.  Bell). 


Fig.  2. — The  liver  in  eclampsia  :  a,  Section  .showing  degenerative  changes-— 
the  spaces  were  mostly  filled  with  fat ;  b,  section  through  infarcted  area  (R.  H. 
Bell). 


PATHOLOGY.  38 1 

was  accompanied  with  some  hydronephrosis ;  in  another  hydro- 
nephrosis alone  was  present.  In  Leopold's  fatal  cases  94  per  cent, 
showed  acute  or  chronic  changes  in  the  kidneys.  Herzfeld,  in  8 1 
postmortem  cases,  found  evidence  of  chronic  nephritis  in  38 ; 
in  25  cases  he  found  parenchymatous  degeneration  of  the  tubules. 

Prutz  has  made  a  careful  study  of  the  kidneys.  In  no  instance 
did  he  find  micro-organisms.  The  veins  were  congested  in  many. 
Fat  droplets  were  obtained  only  in  3  cases  in  the  glomeruH,  vasa 
afferentia,  intertubular  capillaries,  and  other  places.  In  50  per 
cent,  he  found  "  Burstenbesatzen  " — /.  e.,  a  peculiar  fringed  condi- 
tion of  the  epithelial  cells,  mainly  in  the  convoluted  tubules  and 
in  the  ascending  and  descending  parts  of  Henle's  loop.  In  many 
cases  hyaline  casts  were  present  in  the  tubules,  in  whose  epithelium 
cloudy  swelling  and  pigmentation  were  present  in  many  places. 
Occasionally  blood-corpuscles  were  found  in  the  tubules,  and 
areas  of  small-cell  infiltration  were  distinguished. 

It  is  thus  evident  that  a  definite  relationship  cannot  be  estab- 
lished between  eclampsia  and  renal  changes.  The  latter  may  only 
be  in  a  {&\\  cases  an  important  causal  factor.  In  many  cases,  in 
all  probability,  they  are  simply  part  of  a  series  of  widespread 
alterations  produced  by  the  underlying  cause  of  all  eclamptic 
phenomena,  though  other  factors  may  sometimes  assist  in  their 
production.  The  latter  have  already  been  referred  to  in  de- 
scribing the  kidney  of  pregnancy.  Nothing  is  more  certain 
than  that  marked  kidney  disease  may  be  accompanied  by  slight 
eclampsia,  and  that  severe  eclampsia  may  be  associated  with  few 
renal  changes,  or  with  none  in  some  cases.  Regarding  the 
ureters,  only  a  {^v^  observations  have  been  made.  Distinct  dila- 
tation has  been  occasionally  noted,  one  or  both  ureters  being 
affected.  It  may  be  distended  in  its  entire  length  or  in  its  upper 
portion.  Halbertsma  claims  to  have  found  this  change  in  a  num- 
ber of  cases.  Tarnier  and  Budin  state  that  very  slight  dilatation 
of  the  upper  part  of  the  ureter  is  not  infrequent. 

Herzfeld,  in  examining  81  postmortem  cases  in  the  Pathologic 
Institute  of  Vienna,  found  compression  of  both  ureters  in  18  (22 
per  cent.).  This  bilateral  change  has  been  observed  by  him  only 
in  primiparae,  never  in  multiparae,  nor  in  primiparae  in  whom  the 
eclampsia  began  early  in  pregnancy  or  after  labor.  The  ureters 
were  compressed  where  they  crossed  the  brim.  Below  this  point 
they  were  normal ;  above,  they  were  dilated  to  the  size  of  a  man's 
thumb,  the  renal  pelvis  being  also  dilated.  Herzfeld  points  out 
that  the  ureters  are  somewhat  protected  at  the  brim  by  crossing 
the  bifurcation  of  the  common  iliac.  When  the  latter  is  abnormally 
high  or  low  there  is  more  risk  of  ureteric  compression.  Normally 
the  right  ureter  is  more  liable  to  pressure  than  the  left,  as  it  crosses 
the  external  iliac  at  a  lower  level  and  enters  the  pelvis  at  more 
•of  an  angle.     It  is  interesting  to  note  that  in  women  who  have 


382 


ECLAMPSIA. 


become  pregnant  after  the  loss  of  a  kidney  by  operation  no  special 
tendency  to  eclampsia  has  been  observed. 

Liver. — Much  attention  has  been  given  to  the  liver,  Schmorl 
having  been  the  first,  in  1893,  to  describe  fully  changes  in  this 
organ.  Stumpf  has  described  changes  compared  by  him  to  those 
found  in  acute  yellow  atrophy.  The  organ  was  diminished,  the 
tissue  yellow,  with  dark-red  areas.  In  the  center  of  these  areas 
were  granular  and  necrotic  liver  cells  and  red  blood-corpuscles  ; 
many  vessels  were  thrombosed.  Leucin  and  tyrosin  were  fre- 
quently present.  Others  describe  the  liver  as  increased  in  size. 
Bar  found  in    17  cases  that  it  weighed  less  than  1500  gm.  in  2. 

Klebs  described  hemorrhages  be- 
tween hepatic  cells,  and  noted  em- 
bolism of  branches  of  the  portal 
vein,  due  to  blocking  with  de- 
tached liver  cells.  Diihrssen  de- 
scribes hepatic  hypertrophy,  hem- 
orrhages, hepatitis  parenchyma- 
tosa,  and  marked  pallor.  The 
liver  is  sometimes  firm,  sometimes 
friable ;  in  some  cases  it  may  be 
very  easily  broken  down.  Ac- 
cording to  Jiirgens,  Schmorl,  Pil- 
liet,  and  others  the  most  marked 
changes  occur  around  branches  of 
the  portal  vein,  in  many  of  which 
thrombosis  often  occurs. 

The  alterations  found  in  the 
liver  cannot,  be  regarded  as  dis- 
tinctive of  eclampsia.  They  are 
characteristic  of  acute  infectious 
disorders  and  of  those  in  which 
severe  toxemia  is  present.  Their 
presence  in  eclampsia  is  strongly 
suggestive  of  circulating  toxic 
matters  capable  of  disintegrating 
the  hepatic  as  well  as  other  tissues.  There  is  no  doubt  that  the 
more  the  liver  is  disintegrated,  the  more  powerful  the  influence  of 
the  circulating  poisons,  for  undoubtedly  the  organ  has  the  power 
of  destroying  the  latter.  In  connection  with  the  liver  changes, 
reference  may  be  made  to  icterus.  Diihrssen  found  it  in  15.5  per 
cent,  of  his  cases  ;  Olshausen  in  i  per  cent.  The  former  attributed 
it  largely  to  the  free  use  of  chloroform,  a  drug  little  employed  by 
Olshausen  in  eclampsia.,  Stumpf  attributed  it  to  bruising  of  the 
liver  cells  and  injuiy  of  vessels.  It  must,  however,  be  remem- 
bered that  icterus  may  occur  in  pregnancy  apart  from  marked 


Fig.  146. — Naked-eye  appearance 
of  portion  of  liver  removed  from  an 
eclamptic  case  postmortem.  The  dark 
area  represents  an  infarcted  portion  in 
the  degenerated  liver  (R.  H.  Bell). 


PATHOLOGY.  383 

disease,  and  may  be  due  to  catarrh  of  the  common  bile-duct,  to 
pressure,  or  to  other  unknown  causes. 

Central  Nervous  System. — Various  changes  have  been 
found  in  the  brain,  but  these  are  variable;  in  some  cases  nothing 
pathologic  can  be  distinguished.  Goldberg  reported  among  Leo- 
pold's cases  4  with  hemorrhages,  9  with  edema,  4  with  anemia, 
and  2  with  hyperemia.  Schauta,  in  28  cases,  found  25  with 
anemia  and  edema  and  3  with  apoplexy.  Diihrssen,  m  42  cases, 
found  5  with  apoplexy.  In  30  of  Olshausen's  autopsies  in  which 
the  head  was  carefully  examined,  edema  of  the  brain  substance, 
and  often  of  the  pia,  was  found  in  16  cases.  There  were  apo- 
plexies in  5, and  in  2  a  large  blood-clot  in  the  pia;  in  5  hyperemia 
of  the  brain,  the  membranes  being  also  usually  altered.  Hyaline 
degeneration  in  the  vessels  of  the  meninges  has  been  described  by 
some.  It  is  difficult  to  decide  whether  edema,  anemia,  or  hyper- 
emia is  most  frequent.  Hemorrhages  are  infrequent,  and  likely  are 
due  to  the  effects  of  the  convulsive  attacks.  Schmorl  noted 
minute  hemorrhages  in  the  brain  or  membranes  in  65  out  of  73 
cases.  Pachymeningitis  and  leptomeningitis  have  occasionally 
been  found,  but  are  probably  only  a  coincidence. 

Klebs  has  described  emboli  of  cells,  which  he  thought  to  be 
hepatic  in  origin.  (They  were  probably  portions  of  fetal  epiblast 
carried  from  the  uterus.) 

Lungs. — The  most  frequent  change  is  edema,  which  may  be 
due  to  various  disturbances  in  the  respiratory  and  circulatory  sys- 
tems or  to  drugs  used  in  treatment ;  pleural  effusion  may  be  pres- 
ent at  the  same  time.  Sometimes  blood-extravasations  are  found  ; 
sometimes  fat  emboli.  Bronchopneumonia  has  frequently  been 
reported  as  developing  in  eclampsia.  Diihrssen  attributed  it  to 
the  retention  of  the  secretions  containing  germs  and  to  the  use  of 
anesthetics.  Schmorl  described  thrombi  of  multinucleated  masses 
of  protoplasm  in  the  capillaries  ;  these  may  frequently  be  found  in 
normal  women,  being  portions  of  fetal  epiblast,  mainly  syncytium, 
that  have  been  carried  away  by  the  veins  from  the  uterus. 

Heart. — Regarding  the  cardiac  muscle,  no  definite  changes 
have  been  determined.  Fatty  and  granular  degeneration  and 
cloudy  swelling  are  found  in  some  cases  ;  small  hemorrhages  may 
be  noted.  In  73  cases,  Schmorl  noted  minute  hemorrhages,  and 
necrosis  of  muscle  cells  42  times. 

Alimentary  Canal. — No  definite  changes  are  constant.  Con- 
gestion of  the  mucosa  is  found  with  variations  in  the  stomach 
and  small  intestine,  especially  the  duodenum.  In  some  cases 
small  hemorrhages  are  present ;  in  others  erosions  or  ulcerations. 
Fatty  changes  have  also  been  described.  In  some  instances 
emboli  of  distant  cells  are  found  in  capillaries,  probably  removed 
as  the  result  of  violent  convulsions. 

Uterus. — No  characteristic  chancre  is  found  in  the  uterus  in 


384  ECLAMPSIA. 

eclampsia.  In  a  number  of  cases  excessive  size  of  the  organ  is 
found — /.  c,  twin  pregnancy,  hydramnios,  and  large  fetus.  In  325 
cases  of  eclampsia  analyzed  by  Lohlein  there  were  16  of  twins 
and  I  of  triplets,  a  proportion  of  5  per  cent.  The  same  percentage 
was  found  in  Dohrn's  40  cases ;  in  Olshausen's  200  cases  it  was 
^.J  per  cent;  in  Zweifel's  23  cases  it  was  21.7  per  cent.;  in 
Newell's  63  twin  labors  eclampsia  occurred  in  6  cases.  There 
can  be  no  doubt  that  there  is  a  larger  percentage  of  eclampsia  in 
multiple  than  in  single  pregnancies,  and  the  disease  is  probably 
more  fatal  in  the  former. 

Placenta. — There  are  no  distinctive  placental  lesions  in 
eclampsia.  It  has  long  been  taught  that  placental  hemorrhages, 
described  as  infarcts,  are  common.  There  is  no  doubt  that  in- 
farcts, varying  in  size  and  color,  are  frequently  found  in  eclamptic 
cases,  but  they  are  also  found  in  other  diseased  conditions,  and 
frequently  when  the  health  is  good.  In  some  cases  they  may 
not  be  visible  to  the  naked  e}-e.  I  have  already  described 
these  infarcts,  and  ha\e  shown  that  in  the  great  majority  of 
instances  they  are  not  due  to  blood-extravasation,  but  to  the 
formation  of  blood-clots  as  the  result  of  degenerative  changes  in 
the  tetal  tissue  of  the  placenta.  A  real  outpouring  of  blood  is 
\&x\  rare.  In  e\er\'  placenta  from  advanced  pregnancy  these 
changes  are  present  and  small  fibrin-clots  can  be  distinguished. 
The  largest  and  most  numerous  "infarcts"  are  found  in  albu- 
minuric women,  in  eclampsia,  s}'philis,  and  some  other  conditions. 
Favre's  view  that  the  infarct  is  due  to  the  influence  of  a  micro- 
coccus has  not  been  proved. 

Fetus. — Comparatively  little  investigation  has  been  made  on 
the  condition  of  the  fetus  in  eclampsia.  Prutz  found  casts,  uric 
acid,  infarcts,  dilated  veins,  and  unaltered  epithelium  in  i  case. 
Doderlein  studied  the  blood  bacteriologically  in  5  cases  and  the 
urine  in  3  with  negative  results.  Albumin  has  sometimes  been 
found  in  the  urine.  Cassaet  and  Chambrelent  state  that  the 
hepatic  veins  are  much  dilated,  and  that  small  hemorrhages  are 
found  near  the  vessels  or  in  the  interior  of  the  lobules.  The  liver 
cells  may  be  somewhat  compressed  and  occasionally  degenerated. 
Schmorl  has  described  necrotic  foci.  In  the  kidneys  congestion 
is  found,  especially  in  the  region  of  Henle's  tubules,  and  in  some 
parts  blood-extravasation  may  be  noted.  Bar  found  in  i  case 
fatty  degeneration  in  the  tubules  and  considerable  hemorrhage 
under  the  capsule  of  Glisson.  Hemorrhages  have  been  found  in 
the  brain  and  spinal  cord.  These  vascular  and  hemorrhagic 
changes  are  not  distinctive  of  eclampsia ;  they  may  be  found  in 
other  cases  in  which  the  fetus  dies  in  delivery.  Bar,  however, 
believes  that  cell-degeneration  in  the  liver  and  kidney  of  the  fetus 
is  common  in  eclampsia.     Sometimes  the  fetus  is  rigid  at  birth. 

Nature  and  Causation  of  lEclampsia. — There  has  been 


NATURE   AND    CAUSATION  OF  ECLAMPSIA.  385 

much  discussion  as  to  the  nature  and  cause  of  eclampsia,  and 
during  the  second  half  of  the  nineteenth  century  many  views  were 
advanced  to  explain  its  phenomena.  When  Rayer,  of  Paris,  in 
1840,  and  Lever,  of  London,  in  1843,  pointed  out  the  frequency 
of  albuminuria  in  eclampsia,  the  impression  gradually  gained 
ground  that  disturbed  renal  function  associated  with  imperfect 
elimination  of  poisonous  material  caused  the  disease.  It  was  held 
by  some  that  urea  was  the  noxious  element. 

In  185 1  Frierichs  pointed  out  the  resemblance  between  the 
phenomena  of  eclampsia  and  those  of  the  uremic  convulsions  of 
Bright's  disease,  and  held  that  the  conditions  were  identical.  He 
was  supported  by  Wieger  and  Braun,  especially  by  the  latter, 
whose  text-book,  published  in  1857,  did  much  to  make  this  view 
popular.  Frierichs  believed  that  the  cause  of  the  poisoning  was 
a  decomposition  product  of  urea — viz.,  ammonium  carbonate. 
The  uremic  origin  of  eclampsia  has  been  denied  by  many,  and  has 
been  widely  abandoned  since  it  has  been  shown  that  eclamptic 
phenomena  may  occur  without  albuminuria  ;  that  in  the  great 
majority  of  cases  there  has  been  no  previous  renal  disease  ;  that 
the  renal  changes  which  may  be  found  are  not  constant  and  defi- 
nite, but  very  variable,  and  often  very  slight ;  that  the  albuminuria 
frequently  appears  after  the  convulsions  begin  ;  and  that  the  clinical 
phenomena  of  eclampsia  are  not  often  found  in  cases  of  chronic 
Bright's  disease. 

As  regards  the  influence  of  impaired  urinary  excretion,  Cornil 
and  Ranvier  have  pointed  out  the  rarity  of  uremic  convulsions 
in  women  suffering  from  uterine  cancer  that  interferes  with  the 
ureters,  even  where  the  latter  are  dilated  and  hydronephrosis 
is  present.  Seyfert  has  reported  over  70  cases  of  pregnancy  in 
women  with  chronic  Bright's  disease,  in  which  convulsions  oc- 
curred in  only  2.  Hofmeier  has  reported  46  cases,  in  one-third  of 
which  there  was  eclampsia.  Bamberger  found  23  cases  of  eclamptic 
convulsions  in  152  pregnant  and  puerperal  women  with  chronic 
Bright's  disease.  As  regards  Frierichs's  theory,  it  has  been  pointed 
out  by  several  workers  that  ammonium  carbonate  cannot  be  found 
in  the  blood  of  eclamptics. 

Traube  advanced  the  view,  modified  by  Rosenstein  and  sup- 
ported by  Munk,  that  cerebral  anemia  and  edema  were  produced 
as  the  result  of  increased  blood-pressure  and  hydremia  of  the 
blood,  the  former  being  aggravated  by  labor  pains  and  the  latter 
by  the  loss  of  albumin  in  the  urine.  Spiegelberg  opposed  this 
theory,  stating  that  hydremia  and  increased  pressure  cannot  cause 
cerebral  anemia,  and  that  hydremia  is  not  a  special  feature  of 
eclampsia.  Johann  Veit  thought  that  these  factors  were  probably 
the  cause  in  cases  of  renal  insufficiency,  chlorosis  also  probably 
being  a  predisposing  cause  of  eclampsia.  Answering  the  criticism 
that   cerebral   edema   has   been   rarely  found  in   eclampsia,  Veit 

25 


386  ECLAMPSIA. 

States  that  this  condition  may  rapidly  pass  away.  Bartels  regards 
the  cerebral  edema  as  a  result  of  eclampsia.  Olshausen  found 
cerebral  hyperemia  more  frequently  than  anemia,  and  observed  no 
edema  in  many  cases.  He  noted  a  case  in  which  death  occurred 
after  104  convulsions,  the  brain  being  so  diy  that,  on  being  cut,  it 
appeared  more  like  sclerosed  than  edematous  tissue.  He  also 
emphasized  the  frequency  of  fits  apart  from  labor,  and,  therefore, 
from  the  influence  of  increased  blood-pressure  caused  by  pains. 
Falk  has  experimented  on  animals,  and  has  found  it  necessary  to 
introduce  enormous  quantities  of  water  (122  gm.  per  kilo  of 
weight)  in  order  to  cause  convulsions  ;  in  such  cases  the  brain  was 
usually  congested  and  not  edematous  or  anemic. 

Angus  Macdonald  stated  in  1878  that  anemia  of  the  brain  sub- 
stance was  the  essential  cause  of  convulsions.  In  2  fatal  cases 
this  was  found,  though  the  meninges  were  congested,  the  ventricles 
containing  serum.  He  believed  that  the  anemia  was  primarily  due 
to  excrementitious  matter  in  the  blood  stimulating  the  vasomotor 
center  or  setting  up  a  subacute  inflammation  about  it,  whereby 
contraction  of  the  arteries  was  brought  about.  The  poisonous 
matter  in  the  blood  he  believed  to  be  due  to  altered  renal  function. 
Spiegelberg  held  that  eclampsia  was  due  to  cerebral  anemia  and 
to  poisoning  resulting  from  altered  renal  function.  The  latter  he 
believed  to  depend  mainly  upon  disturbances  in  the  kidney  circu- 
lation, which  might  in  some  cases  rapidly  disappear  after  death. 
He  thought  that  the  change  might  be  of  the  nature  of  spasm  of 
the  smallest  vessels,  which  interfered  with  excretion  and  might 
lead  to  destruction  of  the  epithelium  if  it  continued  long  enough. 
He  suggested  that  the  vasomotor  irritation  might  also  affect  the 
cerebral  vessels,  the  source  of  the  irritation  probably  being  the 
uterus,  this  irritability  being  greater  in  primiparae  and  in  cases 
where  the  uterus  is  much  enlarged.  In  emphasizing  the  part 
played  by  peripheral  irritation,  he  pointed  out  that  convulsions 
might  frequently  be  induced  in  eclamptics  in  the  third  stage  by 
uterine  manipulations,  the  peripheral  irritation  caused  by  the 
uterus  in  pregnancy  being  aggravated  during  labor.  Those  who 
believe  in  the  importance  of  cerebral  anemia  point  to  such  experi- 
ments as  those  of  Kussmaul  and  Tenner,  in  which  the  carotids  are 
tied  or  the  animals  bled  from  the  neck,  slight  convulsions  being 
produced. 

In  1882  Halbertsma  criticized  the  former  views  and  stated  that 
eclampsia  is  due  to  the  influence  of  increased  intra-abdominal 
pressure  caused  by  the  growing  pregnant  uterus  interfering  pri- 
marily with  the  ureters  and  secondarily  with  the  kidneys.  He  held 
that  the  special  tendency  to  the  occurrence  of  eclampsia  in  primi- 
parae— hydramnios,  multiple  gestation,  contracted  pelvis — in  all 
of  which  conditions  there  is  excessive  pressure,  strengthens  his 
view. 


NATURE   AND    CAUSATION  OF  ECLAMPSIA.  387 

Ries,  holding'  somewhat  similar  views,  believes  that  in  some 
cases  compression  of  the  ureters  by  the  presenting  part  of  the  fetus 
is  the  most  important  factor.  These  views  have  not  been  accepted 
by  most  authorities.  Halbertsma's  statement  that  dilatation  of 
the  ureters  is  frequent  in  such  cases  has  not  been  corroborated. 
Olshausen  found  dilatation  only  7  times  in  37  autopsies.  He 
and  Stadtfield  have  pointed  out  that  the  ureters  are  sometimes 
dilated  in  non-eclamptic  puerperal  women.  Thus,  in  25  such 
cases  12  presented  unilateral  dilatation  and  4  bilateral.  I  have 
already  considered  the  anatomic  relationships  of  the  ureters  in 
pregnancy,  in  connection  with  altered  renal  functions.  It  must 
be  admitted  that  ureteric  compression  may  in  some  cases  be  a 
factor  in  the  determination  of  an  eclamptic  seizure,  but  there  is 
no  proof  that  it  is  \\\&fons  et  origo  of  the  disease  in  many  cases. 

Stumpf,  in  studying  two  eclamptic  cases  in  1886,  commented  on 
the  resemblance  of  the  liver  changes  to  those  found  in  acute  yellow 
atrophy,  which  suggested  to  him  the  idea  of  acute  poisoning  by 
material  circulating  in  the  blood.  As  leucin  and  tyrosin  were 
found  in  the  liver  and  methemoglobin  in  the  blood,  Stumpf  con- 
cluded that  the  poison  was  some  non-nitrogenous  body  produced 
within  the  organism,  and  he  was  inclined  to  regard  it  as  acetone 
or  aceto-acetic  acid,  which  he  had  detected  in  the  expired  air  and 
urine  of  eclamptics.  This  poison,  he  stated,  irritates  the  kidneys, 
decomposes  hemoglobin,  affects  the  liver,  and  causes  convulsions 
and  coma.  Stumpf  thought  that  the  poison  might  be  developed 
in  the  fetus,  because  the  latter  is  sometimes  in  a  state  of  rigor 
mortis  in  eclampsia,  and  because  its  death  or  removal  often  causes 
cessation  of  the  convulsions.  In  reference  to  Stumpf 's  views,  it  is 
to  be  said  that  acetone  is  not  always  present  in  eclampsia  nor  the 
fetus  in  a  state  of  rigor  mortis.  Moreover,  the  latter  condition 
may  be  found  apart  from  eclampsia.  In  cases  in  which  the  con- 
vulsions develop  after  labor  the  influence  of  the  fetus  is  absent. 
Diihrssen  st-ates  that  acetone  is  a  result,  not  a  cause,  of  eclampsia, 
and  is  due  to  blood-dissolution  and  anesthesia.  Wiener  holds 
that  it  may  be  formed  from  biliary  products  not  excreted. 

As  to  the  part  played  by  the  living  fetus,  various  other  authori- 
ties also  hold  that  it  may  be  a  source  of  the  poison  of  eclampsia, 
that  the  convulsions  may  cease  when  it  dies,  and  that  albuminuria 
and  edema  may  also  disappear  at  the  same  time.  There  may, 
however,  be  no  such  disappearance.  Further,  several  cases  have 
been  described  in  which  eclamptic  convulsions  have  ceased  in  preg- 
nancy, the  fetus  remaining  alive,  the  woman  continuing  normally 
afterward  to  full  time. 

Klebs  advanced  the  suggestion  that  thrombi  formed  of  liver 
cells  displaced  by  pressure  on  the  liver  in  pregnancy  and  labor 
might  have  something  to  do  with  eclampsia.  The  thrombi  de- 
scribed by  Klebs  arc  probably  the  same  as  those  noted  by  Schmorl 


388  ECLAMPSIA. 

and  others,  who  state  that  these  may  be  primary  or  emboHc,  being 
found  both  in  the  veins  and  in  the  arteries.  He  thinks  that  the 
toxic  agent  that  causes  the  coagulation  probably  induces  eclampsia, 
and  suggested  that  it  is  a  ferment,  possibly  related  to  the  placenta. 
There  is  little  doubt  that  the  cell-emboli  noted  by  these  observers 
are  derived  from  the  fetal  chorionic  epiblast  (sync}^tium  and  Lang- 
hans's  layer).  It  is  known  that  they  pass  into  the  circulation 
normally  in  pregnancy,  but  there  is  no  proof  that  they  exercise 
any  deleterious  effect  save  when  they  occur  in  the  malignant  con- 
dition known  as  dccidiioma  nialigniiiii.  Lubarsch,  while  admitting 
that  these  emboli  may  generally  be  placental  in  origin,  states  that 
in  some  cases  they  arise  from  the  liver. 

Within  recent  years  the  view  has  gradualh'  gained  ground  that 
the  most  important  factor  in  the  production  of  eclampsia  is  auto- 
intoxication, the  poisons  resulting  from  various  sources  within  the 
maternal  and  fetal  organisms.  These  poisons  may  be  derived 
from  the  effete  products  of  metabolism  throughout  the  body,  a 
marked  increase  in  the  latter  occurring  in  pregnancy.  In  the  ali- 
mentary canal  they  may  be  taken  in  food  or  drink  and  ma}-  enter 
from  the  bile-passages,  but  are  mainh-  formed  in  the  process  of 
digestion  and  b}'  intestinal  decomposition.  The  emunctories  con- 
tinually get  rid  of  these  noxious  products  as  they  enter  the  circu- 
lation. The  liver  in  particular  exercises  a  destructive  influence 
on  them,  especially  on  those  w'hich  may  enter  from  the  alimentary 
canal  by  the  portal  vein.  The  thyroid  and  parathyroids  are 
believed  b}-  many  to  counteract  the  influence  of  toxic  material. 
The  kidneys  also  exercise  a  very  important  part  in  elimination. 
When  the  function  of  the  li\-er  is  interfered  \\\\X\,  greater  w^ork  is 
thrown  on  the  kidneys. 

Various  efforts  have  been  made  to  detect  the  most  important 
poisons,  but  without  success. 

These  views  in  recent  times  owe  their  inception  to  the  speculations  of 
Bouchard,  first  expressed  in  1887  \Vi\i\s  Lemons  sjir  h's  Aiitointoxicaflons. 
He  stated  that  health  depends  on  a  proper  adjustment  between  the  produc- 
tion and  excretion  of  toxic  substances,  increase  of  the  former  or  diminution 
of  the  latter  leading  to  toxemia  or  autointoxication.  He  considered  that 
the  excretions,  especially  the  urine,  might  ser\e  as  an  index  to  the  toxicity 
of  the  blood  and  tissues.  When  toxic  agents  are  freely  eliminated  a  lower 
degree  of  blood-toxicity  may  be  expected  than  when  the  excretion  is  low. 
Increased  production  of  toxins  might  raise  the  toxicity  both  of  the  blood 
and  urine  even  if  the  excretory  functions  be  normal. 

The  attempts  made  by  Bouchard  and  his  followers  to  establish  the  truth 
of  these  theories  by  experiment  have  not  been  very  satisfactory,  and  in 
some  cases  have  been  very  faulty  and  misleading.  Thus,  in  injecting  urine 
into  the  circulation  of  rabbits,  Bouchard  took  no  precautions  to  obtain  un- 
contaminated  urine.  In  many  instances  it  was  allowed  to  become  altered 
by  micro-organisms.  Moreover,  the  urine  was  injected  much  below  the 
temperature  of  the  animal's  blood.  Nor  was  sufficient  importance  given  to 
the  influence  likely  to  be  exerted  by  the  fluids  of  one  animal  on  those  of 


NATURE   AND    CAUSATION   OF  ECLAMPSIA.  389 

another  class.  The  urotoxic  coefficient,  therefore,  established  by  such  ex- 
periments is  absolutely  unreliable. 

Tarnier  was  the  first  to  study  pregnancy  in  the  light  of  Bouchard's 
theories.  In  1890  he  stated  that  the  urotoxic  dose  from  the  pregnant 
woman's  urine  is  greater  than  the  normal  urotoxic  dose  of  the  healthy  non- 
pregnant adult  estimated  by  Bouchard  ;  or,  in  other  words,  he  found  the 
toxicity  of  the  urine  to  be  diminished  in  pregnancy.  Chambrelent  and 
Demont,  in  1892,  made  a  similar  statement  ;  but  their  experiments  revealed 
such  variations  as  to  make  their  findings  quite  unreliable.  Goria,  in  the 
same  year,  gave  an  account  of  cases  studied  during  and  after  labor.  He 
used  warm,  sterile,  neutral  urine,  and  found  that  its  toxicity  was  very  much 
lower  than  that  mentioned  by  the  other  workers.  As  Eden  points  out,  the 
diminution  was  probably  largely  due  to  his  care  in  preparing  the  urine. 
Blanc,  in  1893,  studied  a  number  of  pregnant  and  puerperal  women.  He 
used  warm,  filtered  urine,  free  from  albumin  and  neutralized  with  soda,  and 
found  that  its  toxicity  was  higher  than  that  obtained  by  Goria.  His  urine 
was  not  sterilized,  however,  and  this  probably  made  some  difference.  Both 
Goria  and  Blanc  noted  an  increase  in  toxicity  after  labor  was  finished.  In 
further  experiments  Blanc  reached  a  different  conclusion — viz. ,  that  the 
toxicity  of  the  urine  is  not  diminished  in  pregnancy. 

Labadie-Lagrave  made  experiments  and  stated  that  the  toxicity  of  the 
urine  diminishes  during  the  first  three  months,  remaining  stationaiy  after- 
ward. In  1895  Ludwig  and  Savor  published  an  account  of  their  experi- 
ments with  the  urine  of  normal  and  eclamptic  pregnant  women.  The  fluid 
was  not  sterilized,  but  was  kept  on  ice  until  used.  They  found  the  toxicity 
a  little  lower  than  that  described  by  Bouchard  for  the  non-pregnant  adult. 
In  the  eclamptics  they  found  great  variations,  but  stated  that  the  average 
urotoxic  dose  was  lowered  during  the  convulsive  stage  and  raised  after- 
ward. Tarnier  and  Chambrelent,  in  their  experiments,  found  that  the 
toxicity  of  the  urine  in  eclampsia  is  extremely  low,  and  accounted  for  this 
by  supposing  that  there  was  an  accumulation  of  toxic  matters  in  the  blood. 
The  statements  of  these  workers  differ  considerably  from  those  of  Ludwig 
and  Savor. 

Volhard,  in  1897,  found  considerable  differences  in  the  to.xicity  of  urine 
from  pregnant  women.  He  noted  that  the  urotoxic  dose  was  increased  by 
boihng,  probably  due  to  the  sterilization.  He  found  differences  according 
to  the  rate  of  injection  into  the  animal's  circulation.  He  found  the  urotoxic 
dose  of  urine  from  the  non-pregnant  adult  considerably  higher  than  that 
mentioned  by  Bouchard.  In  experimenting  with  urine  from  eclamptics  he 
obtained  results  from  which  no  conclusion  could  be  derived. 

Schumacher,  in  1901,  published  an  account  of  some  careful  experiments 
made  in  Fehling's  clinic.  He  first  showed  that  normal  saline  solution 
introduced  into  the  jugular  vein  of  the  rabbit  produced  negative  results. 
As  the  strength  of  the  solution  increased  its  toxicity  increased.  He  found 
that  the  urine  of  women  in  the  non-pregnant  state,  in  pregnancy,  and  in 
labor,  possessing  an  equal  density,  has  the  same  toxicity  ;  that  albumin  does 
not  increase  the  toxicity  ;  that  if  extreme  toxicity  is  found  in  eclampsia  or 
albuminuria,  it  is  due  to  increased  density  of  the  fluid.  He  found  that  re- 
duction of  the  density  to  that  of  normal  urine  practically  reduced  the 
toxicity  correspondingly.  He  points  out  the  diflnculties  of  experimentation 
and  draws  attention  to  the  factors  likely  to  introduce  error. 

Stewart,  in  1897,  described  a  series  of  observations  regarding  the  urine 
of  pregnant  and  parturient  women.  He  used  sterile  and  non-sterile  speci- 
mens and  injected  the  fluid  into  the  peritoneal  cavity  of  animals,  careful 
bacteriologic  examinations  being  made.      His  conclusions  were  as  follows  : 


390  ECLAMPSIA. 

1.  Urine  passed  naturally  contains  a  convulsive  poison  lethal  to  rabbits 
and  mice. 

2.  Urine  drawn  by  catheter  under  strict  asepsis  and  boiled  at  once  is 
harmless. 

3.  If  stale,  unboiled  urine  be  used,  the  toxicity  rises  rapidly  with  the  age 
of  the  specimen. 

4.  All  specimens  of  fresh  urine  that  caused  death  contained  micro- 
organisms at  the  time  of  the  injection. 

When  injected  animals  died,  septic  injection  was  the  cause.  Stewart's 
work  greatly  discredits  the  results  of  the  experiments  carried  on  by  those 
who  have  failed  to  estimate  the  influence  of  micro-organisms  contaminating 
the  urine. 

Various  workers  ha\e  tried  to  test  the  toxicity  of  the  blood.  Rummo 
and  others  have  shown  that  normal  blood  is  toxic  for  different  animals 
when  injected  into  the  circulation,  and  have  stated  that  it  is  more  toxic  in 
diseased  conditions.  Doleris  and  Butte,  in  1886,  separated  from  the  blood 
of  eclamptics  a  crystalline  inorganic  substance  which,  injected  under  the 
skin  of  various  animals,  caused  death  with  convulsions. 

Tarnier  and  Chambrelent,  in  1890,  used  the  blood-serum  of  eclamptics, 
obtained  without  care  as  to  asepsis,  and  decided  that  it  was  more  toxic  than 
normal  serum.  Ludwig  and  Savor  reached  a  similar  conclusion.  Charrion, 
about  the  same  time,  stated  that  he  found  it  to  be  less  toxic.  Volhard's 
results  were  somewhat  similar.  In  1894  Mavret  and  Bosc  endeavored  to 
establish  the  standard  toxicity  of  normal  serum,  and  concluded  that  intra- 
venous injection  is  an  unsuitable  method.  They  found  that  removal  cf  the 
coagulable  elements  greatly  reduced  the  toxicity.  Herter  states  that  the 
percentage  of  urea  in  the  blood  is  not  necessarily  increased  during  the  fits. 
Butte,  however,  says  that  in  bad  cases  it  is  increased  owing  to  impairment 
of  the  liver. 

Schumacher  has  also  experimented  with  blood-serum,  but  has  not  been 
able  to  establish  any  difference  in  toxicity  between  the  serum  of  normal 
parturient  women  and  those  with  eclampsia  or  nephritis.  He  states  that 
the  degree  of  the  disease  has  no  effect  on  the  degree  cf  toxicity  of  the 
urine.  The  amniotic  tluid  and  the  serum  of  the  fetus  are  not  more  toxic 
than  in  normal  cases.  Comparing  the  action  of  urine  and  blood-serum,  he 
states  that  the  former  acts  simply  as  a  salt  solution,  its  action  varying 
according  to  its  concentration.  With  blood-serum  it  is  otherwise,  for  on 
adding  distilled  water  its  toxicity  is  reduced  only  according  to  the  amount 
of  dilution — i.  c\,  a  dose  of  equal  parts  of  serum  and  water  equals  in 
toxicity  that  produced  by  the  amount  of  serum  alone  not  diluted,  whereas 
urine  diluted  in  the  same  proportion  has  no  effect  at  all.  The  serum  acts 
by  virtue  of  toxic  material  contained  in  it. 

In  reference  to  the  various  experiments  with  blood,  Eden  says  that 
unless  separate  definite  toxic  bodies  can  be  obtained  from  it,  experimenta- 
tion along  the  lines  employed  in  the  past  is  certain  to  be  vitiated  by  sources 
of  serious  error.  Indeed,  the  value  of  these  experiments  is  very  doubtful 
as  a  test  of  toxicity  when  it  is  found  that  the  animals  are  often  killed  by 
coagula  produced  in  the  heart  and  blood-vessels,  not  by  poisoning,  whether 
normal  or  eclamptic  blood-serum  is  used.  They  show  in  reality  only  a 
difference  in  the  power  of  producing  coagulation.  When  the  serum  is 
injected  under  the  skin  or  into  the  peritoneum,  much  larger  quantities  are 
required  to  produce  death.  Thus,  Bar  found  that  20  c.c.  per  kilo  could  be 
injected  subcutaneously  into  a  rabbit  without  fatal  results,  when  an  intra- 
venous dose  of  3  c.c.  would  cause  death. 

Recently  efforts  have   also  been  made  to  prove  by   experiments   that 


NATURE   AND   CAUSATION  OF  ECLAMPSIA.  39 1 

renal  elimination  is  diminished  in  pregnancy,  especially  in  eclampsia. 
Inert  coloring-matter  is  introduced  into  the  body,  and  the  interval  that 
elapses  before  it  appears  in  the  urine  noted  ;  also  the  rate  and  regularity 
with  which  elimination  continues  and  is  completed.  The  results  are  incon- 
clusive. 

In  the  endeavor  to  determine  the  nature  of  the  toxic  agents, 
experiments  have  been  made  with  substances  known  to  result 
from  body  metabolism.  Thus,  Landois  induced  convulsions  and 
coma  by  exposing  the  anterior  and  lateral  cerebral  convolutions 
and  applying  kreatin,  kreatinin,  dried  urinary  sediment,  sodium 
and  potassium  phosphates,  and  other  bodies.  Several  workers 
have  regarded  the  potassium  salts  as  important  toxic  agents  in 
uremia  and  eclampsia. 

Since  the  publication  by  Doderlein  of  the  results  of  bacteriologic 
examinations  in  cases  of  eclampsia,  many  authors  have  thought 
that  this  disease  might  be  due  to  micro-organisms.  Since  May, 
1898,  Levinowitsch  has  made  systematic  bacteriologic  examina- 
tions of  the  blood  in  eclampsia,  with  the  following  results :  In 
fresh  blood  from  44  cases  large  regular  cocci,  of  round  and  oval 
forms,  were  found,  which  showed  extraordinary  activity,  the 
round  forms  being  smaller  than  the  oval  ones ;  the  cocci  were 
often  arranged  in  pairs,  or  as  diplococci.  In  28  cases  the  eclamptic 
blood  was  placed  in  bouillon,  gelatin,  and  agar,  and  25  times  a 
complete  culture  was  obtained  ;  the  micrococcus  flourished  at  the 
normal  body  temperature,  and  on  such  media  as  placental  tissue. 
In  three  or  four  days  the  culture  showed  large  oval  cocci,  arranged 
in  twos  or  fours,  and  exhibited  extreme  mobility.  The  micro- 
coccus was  stained  by  anilins ;  cilia  were  demonstrated.  Old 
cultures  showed  curiously  involuted  forms,  with  many  oval  ones 
of  considerable  size.  Some  cocci  had  a  central  stained  portion 
(spore  ?) ;  one  form  had  a  long,  thread-like  attachment  that  moved 
like  a  tail ;  another  variety  was  shaped  like  a  dumb-bell.  These 
cocci  were  mostly  found  in  blood  taken  during  the  first  seizure, 
but  blood  was  also  examined  within  two  days  after  the  last  attack  ; 
in  two  days  after  the  last  attack  the  involuted  forms  with  the 
central  uncolored  portion  were  found. 

The  micrococcus  was  pathologic  to  guinea-pigs.  In  twenty- 
eight  to  thirty  days  after  subcutaneous  injection  of  the  clear  culture 
acute  anemia  was  produced,  following  hemorrhagic  endometritis  ; 
in  one  case  of  injection  of  the  clear  culture  in  a  bitch,  transient 
convulsive  attacks  were  observed  in  the  muscles  of  the  vagina.  In 
one  case  the  same  coccus  was  found  in  the  blood  of  the  newborn 
child  of  an  eclamptic  mother  ;  in  two  infants  attacks  of  eclampsia 
were  observed.  In  the  blood,  both  of  pregnant  women  and  those 
at  term  who  had  no  typical  eclampsia,  but  had  nevertheless  suffered 
froni  headache,  edema,  vomiting,  etc.,  the  same  micrococci  were 
found  in   small   numbers.     The  dumb-bell  form  appeared  some- 


392  ECLAMPSIA. 

times  in  the  mononuclear  and  polynuclear  leukocytes,  where  they 
may  be  distinctly  seen  when  a  fresh-blood  specimen  is  examined. 

H.  Miiller  and  Albert  have  advanced  the  view  that  eclampsia 
is  a  general  intoxication,  due  to  the  action  of  bacteria  within,  and 
the  resorption  of  their  products  from,  the  uterine  cavity.  In  preg- 
nancy the  bacteria  are  believed  to  be  latent  during  the  early  months, 
before  the  convulsions  begin. 

Stroganoff  has  urged  the  infective  nature  of  the  disease  for  the 
following  reasons  :  It  is  a  widespread  infection,  involving  many 
organs  ;  it  develops  acutely  ;  the  fever  accompanying  it,  especially 
the  postmortem  thermic  elevation,  is  peculiar  to  infective  disease ; 
one  attack  appears  to  confer  immunit}' ;  the  disease  is  more 
common  in  populous  centers. 

In  conclusion  it  must  be  admitted  that  while  many  observa- 
tions have  been  made  in  eclampsia,  very  little  has  followed  the 
attempts  to  analyze  these  and  to  arrange  them  in  their  proper 
relationship  to  the  disease.  No  certain  cause  has  been  definitely 
established.  It  is  probable  that  different  etiologic  factors  are  asso- 
ciated in  the  production  of  the  fits.  In  some  cases  many  of  these 
may  be  combined  ;  in  others  few.  Sometimes  one  factor  may  be 
very  prominent  and  the  others  of  little  account.  No  scientific 
classification  of  the  various  combinations  can  be  made.  The  factors 
may  be  referred  to  generally  as  follo^\•s  : 

Of  great  importance  are  toxic  agents  circulating  in  the  blood, 
derived  from  sources  already  mentioned.  They  are  probably  most 
active  in  the  gravest  cases  of  eclampsia.  They  affect  various 
tissues  differently  in  different  cases,  and  are  probably  responsible 
for  most  of  the  degenerations  found  in  the  liver  and  kidneys.  Im- 
paired action  of  the  emunctories,  especially  of  the  kidneys,  plays  a 
role  in  some  cases  by  interfering  with  the  elimination  of  circulating 
toxic  agents  ;  therefore  pressure  on  the  ureters  and  kidneys,  the 
kidney  of  pregnancy,  nephritis,  and  reflexly  induced  renal  anemia 
may  occasionally  play  a  part.  Faulty  elimination  of  the  bowel  is 
probably  not  infrequently  a  cause  of  retention  of  toxic  matter. 
Another  factor  is  nervous  and  psychic  irritability  or  excitability. 
In  some  cases  this  may  determine  the  onset  of  an  attack.  Some 
authors  think  there  is  a  special  type  of  nervous  organization  in 
which  there  is  a  particular  liability  to  disturbance.  It  is  widely 
believed  that  in  eclamptic  cases  in  which  the  kidney  or  liver  changes 
are  slight  the  attacks  are  due  to  the  influence  of  circulating  poisons 
on  abnormally  irritable  cortical  psychomotor  centers  and  sub- 
cortical ganglia.  Von  Herff  thinks  that  there  is  little  difference 
between  the  phenomena  of  epileptic,  uremic,  and  eclamptic  attacks, 
and  that  all  are  due  to  the  influence  of  different  causes  acting  on 
these  centers. 

Recently  Nicholson,  of  Edinburgh,  has  suggested  that  some  cases  of 
eclampsia  might  be  related  to  inadequacy  of  the  thyroid  and  parathyroid 


77?^^  TMENT.  393 

glands.  He  refers  to  Lange's  25  cases  of  pregnancy  in  which  the  normal 
hypertrophy  of  the  thyroid  did  not  occur,  and  in  which  albuminuria,  and 
sometimes  eclampsia,  developed.  Others  have  also  noted  that  the  thyroid 
is  frequently  small  in  eclampsia. 

The  thyroid  is  one  of  the  organs  closely  related  to  metabolism,  iodothyrin 
being  an  essential  to  the  organism.  In  cases  of  absent  or  small  thyroid 
there  are  faulty  metabohsm  and  impaired  excretion.  Iodothyrin  administra- 
tion stimulates  metabolism  and  increases  the  excretion  of  urea.  Nicholson 
regards  eclampsia  as  the  result  of  some  failure  in  the  process  of  proteid 
metabolism,  associated  with  a  deficiency  of  iodothyrin,  or  to  impaired 
activity  of  the  secretion,  though  the  liver  and  other  "  defence  organs  "  may 
also  be  at  fault.  He  points  out  that  the  phenomena  of  an  eclamptic  attack 
resemble  those  following  experimental  removal  of  the  whole  thyroid  system 
in  animals.  He  thinks  that  the  thyroid  may  be  given  a  primary  role  in  the 
causation  of  eclampsia. 

Spasm  of  the  renal  vessels  tends  to  occur  when  the  influence  of  the. 
thyroid  is  diminished  (perhaps  aided  by  the  action  of  the  suprarenal  secre- 
tion, which  contracts  the  arteries).  He  urges  the  use  of  fresh  iodothyrin  or 
thyroid  extract  both  in  the  pre-eclamptic  and  in  the  eclamptic  condition, 
even  to  the  point  of  causing  thyroidism,  in  which  state  vessels  are  fully  re- 
laxed. Activity  of  the  skin  and  kidneys  is  thereby  promoted,  though  with 
considerable  variations  in  different  cases.  Thyroid  extract  may  have  some 
specific  action  in  rendering  certain  toxic  substances  harmless.  It  is  stated, 
for  example,  that  the  parathyroids  normally  render  enterotoxins  innocuous. 
Morphin  is  regarded  by  Nicholson  as  a  valuable  adjunct  to  the  thyroid 
extract. 

Treatment. — There  is  considerable  difference  of  opinion  re- 
garding the  treatment  of  eclampsia,  which  is  to  a  great  extent 
empiric  in  nature.  That  this  is  the  case  is  not  surprising  in  view 
of  the  many  speculations  current  regarding  the  nature  of  the 
disease. 

Preventive  Treatment. — When  a  pregnant  woman  exhibits 
any  of  the  signs  or  symptoms  that  have  been  described  as  pre- 
monitory to  eclampsia, — i.  e.,  albuminuria,  edema,  deficiency  of 
urine  or  of  total  solids,  alimentary  disturbances,  headache,  lassi- 
tude, rapidity  and  high  tension  of  pulse, — she  should  be  placed  on 
a  restricted  diet.  Jacoud  and  Tarnier  have  been  strong  advocates 
of  milk.  This  should  be  administered  in  the  forms  most  palatable 
to  the  patient — warm,  cold,  hot,  boiled,  mixed  with  hot  water, 
Vichy,  or  other  table  waters.  A  pinch  of  salt  or  of  sodium  bicar- 
bonate often  renders  milk  more  ea.sily  digestible.  It  should  always 
be  sipped  slowly.  Two  or  three  liters  or  even  more  should  be 
taken  daily.  After  each  meal  it  is  advisable  to  rinse  the  mouth 
with  a  solution  of  sodium  borate  or  listerin.  All  exposure  to  cold 
or  dampness  should  be  avoided.  Flannel  should  be  worn  next 
the  skin  and  daily  warm  baths  taken.  Vigorous  massage  and 
shampooing  of  the  skin  are  very  advantageous  unless  there  is  some 
contraindication,  and  moderate  exercise  may  be  taken.  The 
patient  must  avoid  all  worry  and  excitement.  Sexual  intercourse 
should   be   prohibited.     If  the  premonitory  signs  and  symptoms 


394  ECLAMPSIA. 

are  marked,  the  patient  should  be  kept  quiet  in  her  room  or  even 
in  bed.  The  bowels  must  be  kept  regularly  open,  various  well- 
known  medicines  being  used  for  this  purpose.  To  increase  the 
activity  of  the  kidneys  the  author  has  employed  the  following 
modified  Semmola's  mixture  :  Sodium  iodid,  1 5  gr. ;  sodium  phos- 
phate, 30  gr. ;  sodium  chlorid,  90  gr. ;  water,  36  oz.  Several 
glasses  may  be  taken  daily  alone  or  with  milk.  Diuretin,  digi- 
talis, and  other  diuretics  may  be  used.  In  threatening  cases  high 
bowel  injections  of  normal  saline  solution  may  be  given — a  pint 
two  or  three  times  daily ;  its  diuretic  action  is  increased  if  30  to 
60  gr.  of  sodium  acetate  be  added,  as  Jardine  has  pointed  out. 
Diuretin  and  glonoin  are  also  valuable  diuretics.  Pilocarpin  should 
not  be  used  because  of  the  risk  of  edema  of  the  lungs  and  glottis. 
Nicholson  advocates  full  doses  of  fresh  iodothyrin  or  thyroid  ex- 
tract, for  reasons  already  given.  \Mien  there  is  much  nervous 
excitability,  chloral  or  sodium  bromid  may  be  given. 

Morphin  is  used  by  many  for  this  purpose  only  as  a  last  resort, 
on  the  ground  that  if  the  kidneys  be  much  affected,  this  drug  is 
eliminated  with  difficulty,  its  accumulation  tending,  therefore,  to 
produce  toxic  symptoms.  It  is,  however,  urged  by  several  that 
the  risk  of  dangerous  cumulative  effects  of  morphin,  when  the 
renal  activit}'  is  impaired,  is  much  exaggerated  and  unwarranted. 
Nicholson  strongly  urges  the  use  of  morphin,  pointing  out  that  it 
causes  relaxation  of  the  vessels  and  so  promotes  diuresis  ;  that  it 
inhibits  metabolism  temporarily  and  so  causes  less  toxic  matter  to 
be  produced,  and  that  it  counteracts  the  nervous  phenomena  of 
eclampsia. 

Stroganoff  has  strongly  advocated  the  combined  use  of  morphin 
and  chloral,  the  former  for  its  influence  on  the  sensory  centers  and 
the  latter  to  control  convulsions.  The  number  of  the  attacks  is 
reduced  and  the  chances  of  recovery  are  greatly  increased,  ac- 
cording to  this  authority.  Newell  states  that  this  method  is  better 
in  postpartum  than  in  antepartum  eclampsia. 

Venesection  may  be  employed  wdien  symptoms  are  very  un- 
favorable, especiallv  when  renal  activity  is  much  impaired  and  the 
blood-pressure  high.  In  grave,  threatening  conditions,  particu- 
larly after  the  employment  of  the  measures  already  described,  it 
is  justifiable  to  empty  the  uterus  prematurely;  or,  if  the  woman 
be  already  in  labor,  delivery  may  be  hastened  by  dilatation  of 
the  cervix,  delivering  by  forceps,  or  turning.  Chloroform  anes- 
thesia should  be  used.  Antiseptics  whose  absorption  may  be 
deleterious — i.  c,  corrosive  sublimate — should  not  be  employed. 
Several  of  these  procedures  have  been  strongly  opposed  by  a 
number  of  authorities.  While  the  indiscriminate  indication  of 
premature  labor  in  all  cases  in  which  premonitory  symptoms  of 
eclampsia  occur  cannot  be  too  strongly  condemned,  its  employ- 
ment in  certain  selected  cases  is  to  be  recommended. 


TREA  TMENT.  395 

Labor  may  be  induced  by  dilating  the  cervix  and  introducing 
a  Barnes  or  a  Champetier  de  Ribes  bag,  which  is  left  in  the  canal 
in  order  to  stimulate  the  uterus  to  contractions.  In  urgent  cases 
it  may  not  be  advisable  to  allow  nature  to  empty  the  uterus,  but 
to  dilate  and  deliver  artificially. 

During  an  Attack. — The  patient  should  be  placed  in  bed  and 
constantly  watched.  The  hot-air  bath  or  hot  pack  may  be  used 
to  promote  diaphoresis,  the  pulse  being  closely  observed.  During 
the  convulsions  it  may  be  necessary  to  control  her  during  ex- 
cessive movements.  To  prevent  biting  of  the  tongue  a  rolled 
towel  or  a  piece  of  wood  or  rubber  should  be  placed  between  her 
teeth.  When  the  seizures  are  violent,  they  may  be  controlled  by 
chloroform  inhalations.  This  drug  has  been  used  in  various  ways, 
continuously  or  intermittently.  Its  influence  in  causing  fatty  de- 
generation in  the  heart,  liver,  kidneys,  etc.,  should  always  be  re- 
membered, and  it  should,  therefore,  be  used  to  modify  only  very 
severe  convulsions.  It  should  be  administered  when  the  latter 
threaten,  in  order  to  produce  narcosis,  being  withheld  after  the 
fits.  Rectal  administration  of  chloral  is  used  by  many  authorities 
in  addition  to  chloroform.  It  is  usually  freely  eliminated  from 
the  body  and  does  not  tend  to  accumulate  in  poisonous  doses. 

Veratrum  viride  is  highly  praised  by  many,  especially  in 
America.  It  should  be  used  only  when  the  patient  is  strong  and 
the  pulse  full  and  regular ;  when  the  latter  is  weak  and  irregular, 
the  drug  is  contraindicated.  It  should  be  given  only  when  the 
patient  is  lying  down.  It  causes  a  reduction  in  the  pulse-rate,  and  is 
believed  to  promote  renal  and  skin  activity,  lower  the  temperature, 
and  relax  the  cervix.  An  initial  dose  of  1 5  to  20  minims  of  the 
fluid  extract  should  be  given  hypodermically.  This  should  be 
followed  every  thirty  minutes  by  a  dose  of  10  minims  until  the 
pulse  remains  below  63  a  minute,  eclamptic  convulsions  being 
rare  with  a  pulse  of  this  low  rate.  Should  collapse  and  vomiting 
occur,  the  drug  must  be  discontinued,  the  patient  kept  recumbent, 
and  alcoholic  stimulants  given.  Morphin  is  used  by  many  authori- 
ties in  preference  to  the  drugs  described.  Nicholson  has  noted 
the  beneficial  influence  of  thyroid  extract  on  the  vomiting.  Ice- 
bags  applied  to  the  back  of  the  head  and  neck  seem  in  some  cases 
to  modify  the  convulsions. 

Inhalation  of  oxygen  has  been  highly  praised  by  some  authori- 
ties. It  may  be  of  benefit  when  the  patient  is  asphyxiated.  If 
the  bowels  have  not  been  recently  freely  moved,  a  strong  purga- 
tive should  be  given  by  the  mouth.  When  the  patient  is  uncon- 
scious, a  k'w  drops  of  croton  oil  mixed  with  a  little  olive  oil  should 
be  placed  on  the  back  of  the  tongue  in  order  that  they  may  be 
swallowed  reflexly. 

Recently  the  practice  of  administering  normal  saline  solution 
subcutaneously   or  by   the   rectum    has   been    recommended   by 


396  ECLAMPSIA. 

several  authorities.  The  rectal  route  should  be  chosen  if  several 
injections  are  to  be  given,  on  account  of  the  greater  convenience 
and  freedom  from  risk  of  septic  infection,  the  fluid  being  rapidly 
enough  absorbed  into  the  system.  The  value  of  the  saline  solu- 
tion is  stated  to  consist  in  the  promotion  of  diuresis  and  diaphoresis 
and  in  the  dilution  of  poisons  circulating  in  the  blood.  It  un- 
doubtedly leads  to  a  dilatation  of  the  arteries  in  the  kidneys  and 
elsewhere. 

Venesection  has  been  considerably  recommended  and  may  be 
helpful  when  the  patient  is  robust,  the  pulse  full  and  of  high 
tension,  and  cyanosis  marked.  If  the  view  as  to  the  circulation  of 
poisons  be  correct,  it  is  logical  to  remove  some  of  the  poisoned 
blood,  as  well  as  to  dilute  what  is  left  in  the  vessels  by  the  intro- 
duction of  saline  solution  into  the  system  in  the  manner  described. 
At  least  300  gm.  of  blood  may  be  withdrawn  from  the  arm  or  neck. 
Venesection  helps  to  reduce  blood-pressure. 

It  has  been  frequently  noted  in  cases  of  eclampsia  that  im- 
provement has  followed  the  birth  of  the  fetus.  Consequently  the 
practice  has  become  prevalent  in  many  schools  of  inducing  labor 
immediately  or  of  hastening  it  if  it  has  already  begun.  There  has 
been  much  dispute  as  to  the  advisabilit}'  and  limitations  of  this 
procedure.  Some  authorities — /.  r.,  Charpentier  and  Winckel — 
hold  that  the  uterus  should  not  be  interfered  with  save  after  com- 
plete dilatation  of  the  cervix,  as  they  believe  that  the  disturbance 
caused  by  artificial  dilatation  induces  convulsive  seizures.  Others 
hold  that  delivery  should  be  carried  out  as  quickly  as  is  possible 
without  serious  damage  to  the  patient,  whether  or  not  labor  has 
begun,  for  the  reason  that  the  fits  usually  cease  afterward.  Several 
authorities  hold  that  this  reason  has  been  exaggerated.  Herman 
has  recently  collected  a  series  of  2142  cases  of  eclampsia,  in  905 
of  which  the  convulsions  ceased  after  delivery,  while  in  816  they 
continued.  He  holds,  therefore,  that  operative  delivery  is  not 
urgently  required. 

Among  those  who  believe  in  carr}-ing  out  artificial  delivery 
there  is  a  difference  of  opinion  as  to  the  best  means  of  performing 
the  operation.  When  the  cervix  is  fully  dilated,  forceps  may  be 
used ;  or  if  the  child  be  dead,  embryulcia  may  be  carried  out,  if 
the  operator  deems  it  safer  and  more  expeditious.  In  undilated 
or  partly  dilated  conditions  of  the  cervix  various  procedures  may 
be  employed.  (These  are  described  in  the  section  dealing  with 
methods  of  inducing  labor.)  If  a  physician  be  present  when  a 
pregnant  woman  carrying  a  viable  fetus  dies  of  eclampsia,  it  is  his 
duty  to  advise  immediate  postmortem  Caesarean  section,  in  the 
hope  of  saving  the  infant.  Bauer  has  recently  collected  reports 
of  8  such  cases  in  which  4  infants  were  saved. 

In  the  Posteclamptic  State  of  Stupor. — In  this  state  the  hot- 
air  bath  or  hot  pack  may  be  used  to  favor  diaphoresis,  the  pulse 


DEFINITION.  397 

being  carefully  watched.  Croton  oil  may  be  given  as  above  de- 
scribed, or  a  large  dose  of  a  saline  purgative  may  be  administered 
by  a  stomach-tube.  Normal  saline  injections  containing  sodium 
acetate  should  be  given  by  the  bowel  (i  pint  every  five  or  six 
hours).  Venesection  may  be  carried  out  where  there  is  asphyxia, 
if  not  previously  employed.  Oxygen  inhalation  may  be  used. 
Alcohol  and  strychnin  may  be  given  if  there  are  collapse  and  evi- 
dence of  failing  heart. 

As  the  patient  recovers  and  is  able  to  take  nourishment  the  diet 
should  at  first  consist  of  milk,  plasmon,  cocoa  plasmon,  barley 
and  rice  soups,  toast,  and  gruel. 

Eclamptics  should  not  be  allowed  to  nurse  their  infants. 


CHAPTER    XV. 
ECTOPIC  PREGNANCY. 

Definition. — By  an  ectopic  pregnancy  is  meant  one  that  de- 
velops outside  of  the  uterine  cavity.  By  many  this  term  is  con- 
sidered as  synonymous  with  extra-uterine.  The  latter,  however, 
cannot  be  strictly  held  to  include  interstitial  gestations,  and  is, 
therefore,  abandoned  by  the  author  for  the  former  expression, 
which  was  first  employed  by  Robert  Barnes  in  1873. 

Btiologfy. — For  a  long  time  it  has  been  held  that  an  ovum 
fertilized  at  the  fimbriated  end  of  the  tube  might  develop  anywhere 
on  the  tubal  mucosa,  normal  or  abnormal,  if  it  were  prevented 
from  passing  into  the  uterus  by  various  mechanical  forces — i.  v., 
tumors  of  the  tube-wall  or  of  neighboring  structures  pressing  upon 
it,  polypi  in  the  lumen,  constriction  of  the  tube  by  adhesions,  dis- 
placement of  diverticula  of  the  tube-lumen,  interference  with  the 
peristaltic  action  of  the  tube  as  the  result  of  thickness  or  adhesions, 
and  destruction  of  the  cilia  in  the  tube  by  inflammation.  Various 
other  causes  have  been  assigned,  such  as  falls,  fright,  mental 
excitement,  etc. 

In  1895  the  author  pointed  out  that  these  views  were  largely 
speculative.  He  showed  that  while  frequently  these  mechanical 
factors  might  be  associated  with  ectopic  pregnancy,  there  was  no 
proof  that  they  were  the  ultimate  factors  in  its  causation.  He 
demonstrated  the  existence  of  the  decidual  reaction  in  the  tubal 
mucosa  in  all  cases  of  tubal  pregnancy,  and  advanced  the  view 
that  the  fertilized  ovum  could  develop  only  on  tissue  capable  of 
undergoing  the  genetic  reaction.  Normally  in  the  human  female 
this  reaction,  occurring  as  the  result  of  fertilization,  takes  place  in 
the  body  of  the  uterus.     Its  occasional  occurrence  in  other  por- 


398  ECTOPIC  PREGNANCY. 

tions  derived  from  the  Mullerian  tract — /.  r.,  Fallopian  tube — is 
to  be  regarded  as  a  reversion  in  these  tissues  to  an  earlier  mam- 
malian type,  either  in  structure  or  in  reaction  tendency. 

The  fertilized  ovum,  coming  in  contact  with  any  portion  of  the 
Mullerian  tract  capable  of  establishing  with  it  that  relationship 
that  is  necessary  to  its  development,  may  become  attached  and 
grow  just  as  readily  as  if  it  were  lodged  in  the  uterine  cavity. 
Since  the  great  majority  of  ectopic  gestations  occur  within  the 
tube-lumen,  it  is  very  easy  to  understand  why  all  mechanical  con- 
ditions that  interfere  with  the  transit  of  the  ovum  through  the 
tube  might  play  a  part  in  determining  the  site  of  its  attachment. 
It  is,  however,  an  unjustifiable  assumption  to  hold  that  the  ovum, 
if  simply  obstructed  in  its  downward  movement,  may  develop  in 
a  tubal  mucosa  that  is  perfectly  normal  or  altered  by  inflamma- 
tion. 

When  the  phylogeny  of  the  Mullerian  tract  is  borne  in  mind, 
it  is  not  surprising  that  there  should  be  found  occasionally  in  the 
human  subject  a  condition  of  tubal  mucosa  in  which  character- 
istics normally  limited  to  the  uterine  mucosa  may  be  found.  The 
evolution  of  the  single  uterus  of  the  human  female  from  the 
bicornute  condition  of  the  lower  animals,  in  which  more  than 
one  ovum  normally  develops,  has  been  accompanied  by  a  differ- 
entiation in  structure  and  function,  the  upper  portion  of  the  Miil- 
lerian  tract  on  either  side — viz.,  the  Fallopian  tube — acting  as  an 
^gg  carrier ;  the  lower  portion — viz.,  the  uterus — serving  as  the 
^^•g  holder.  The  author  strongly  holds  that  there  is  no  proof 
whatever  that  ectopic  pregnancy  begins  its  development  on  any 
other  than  Mullerian  tissue.  Primaiy  development  on  the  peri- 
toneum has  never  yet  been  established.  A  few  cases  described  as 
ovarian  pregnancy,  in  which  it  is  claimed  that  the  ovum  has  de- 
veloped in  ovarian  tissue,  are  probably  only  instances  of  growth 
of  the  ovum  on  portions  of  the  Mijllerian  tract  in  close  relation- 
ship with  the  ovary. 

Classification. — Almost  all  ectopic  pregnancies  begin  to 
develop  in  contact  with  some  portion  of  the  tubal  mucosa.  They 
may,  therefore,  be  considered  for  purposes  of  study  in  the  follow- 
ing groups : 

I.  Ampullar,  in  which  the  gestation  begins  in  the  ampulla  or 
middle  portion  of  the  tube.     This  includes  the  majority  of  cases. 

II.  Interstitial,  in  which  the  ovum  develops  in  that  portion 
of  the  tube  situated  in  the  wall  of  the  uterus. 

III.  Infundibular,  in  which  the  gestation  develops  in  the 
outer  end  of  the  tube-lumen  or  among  the  fimbriae. 

IV.  Anomalous  Varieties. — Among  these  may  be  placed  ges- 
tations that  develop  in  accessory  fimbriated  extremities  or  in  tubal 
diverticula.  Here  also  should  be  included  those  which  develop 
on  the  ovarian  fimbria  or  in  detached  portions  of  Miillerian  tissue 


VARIETIES  STUDIED   IN  DETAIL.  399 

— /.  e.,  those  attached  to  or  embedded  in  the  ovary.  ■  In  the  latter 
category  should  be  placed  some  recently  described  cases  of  ovarian 
pregnancy. 

V.  Cornual  pregnancy,  in  which  the  ovum  develops  in  the 
undeveloped  horn  of  a  bicornute  uterus,  though  not  strictly 
speaking  ectopic,  is  usually  considered  in  this  connection. 

Varieties  Studied  in  Detail. — I.  Ampullar. —  i.  Persistent. 
— Very  few  cases  have  been  recorded  where  pregnancy  has 
reached  an  advanced  stage  without  rupture.  As  the  tube  en- 
larges it  may  occupy  various  positions  in  the  pelvis  ;  in  late  stages 
it  may  sometimes  be  found  entirely  above  the  brim,  though  it 
generally  partially  occupies  the  pelvic  cavity.  It  may  be  some- 
what pedunculated,  though  its  mobility  is  usually  early  impaired 
by  the  formation  of  adhesions  to  surrounding  structures. 

2.  Cases  ivhicJi  Rupture  into  the  Broad  Ligament. — {a)  Per- 
sistent.— Some  cases  after  rupture  continue  their  development. 
These  have  been  variously  denominated  as  "  extraperitoneal," 
"  tuboligamentous,"  "  subperitoneopelvic,"  and  "  broad-ligament." 
When  the  gestation  develops  upward  in  the  abdominal  cavity 
without  opening  into  the  peritoneal  cavity,  the  term  "  subperitoneo- 
abdominal "  has  been  used  to  describe  it.  The  rupture  takes 
place  usually  between  the  eighth  and  fourteenth  weeks  ;  some- 
times at  an  earlier  or  later  period.  It  is  due  to  a  gradual  thinning 
and  stretching  of  the  lower  part  of  the  tube-wall  within  the  layers 
of  the  broad  ligament.  The  ovum  may  rapidly  or  gradually 
extend  through  the  opening,  the  broad  ligament  gradually  be- 
coming distended  by  it.  The  gestation  then  tends  to  increase  in 
all  directions  and  may  descend  to  a  very  low  level  in  the  pelvic 
floor,  displacing  the  uterus,  bladder,  and  rectum,  and  stripping  the 
peritoneum  from  these  structures  and  from  the  pelvic  wall. 

In  some  cases  the  uterus  may  be  pushed  against  one  side  of 
the  pelvis,  or  it  may  be  pushed  markedly  toward  the  front  when 
the  gestation  burrows  under  the  peritoneum  behind  it.  As  the 
extension  occurs  upward  into  the  abdomen  the  peritoneum  is 
stripped  from  the  abdominal  parietes  and  from  portions  of  the 
viscera.  The  position  of  the  placenta  varies  in  different  ca.ses. 
When  it  is  situated  mainly  lowermost  in  the  tube,  it  may  gradually 
extend  between  the  layers  of  the  broad  ligament,  being  found 
chiefly  within  the  pelvis,  even  if  gestation  should  reach  an  ad- 
vanced stage.  When  it  is  mainly  uppermost  in  the  tube,  it  may 
be  greatly  elevated  upward  into  the  abdomen  behind  the  peri- 
toneum, and  through  the  adhesions  that  form  on  the  outer  surface 
of  the  tube  it  may  lie  in  close  relationship  to  the  parietes  or  to 
the  viscera. 

{b)  Rupture  of  the  Extraperitoneal  Variety  into  the  Peritoneal 
Cavity. — After  the  escape  of  a  tubal  pregnancy  into  the  broad 
ligament  there  may  be  a  secondary  rupture   into  the  peritoneal 


400 


ECTOPIC  PREGNANCY. 


cavity.  This"  may  take  place  immediately  or  at  various  periods 
afterward.  The  site  of  rupture  is  most  frequently  the  upper  pos- 
terior part  of  the  sac-wall. 

(<r)  Termination  of  the  Gestation. — Instead  of  continuing  its 
development  after  rupture  into  the  broad  ligament,  the  gestation 
m.ay  come  to  an  end  in  various  ways.  Blood-extravasation  may 
take  place  to  such  an  extent  that  the  placenta  is  detached  or 
greatly  torn,  a  hematoma  being  produced,  in  which  are  scattered 


Fig.  147. — Vertical  mesial  section  of  a  woman  who  died  after  removal  of  a  fetus 
from  amniotic  cavity  of  a  full-time  tuboperitoneal  ectopic  gestation  :  a,  Promontory  ; 
b,  symphysis;  c,  uterus  ;  d,  bladder;  e,  upper  end  of  sac  lined  by  amnion,  in  which  lay 
the  fetus  ;  f,  lower  end  of  sac  lined  by  amnion;  g,  great  omentum,  altered  in  character, 
being  dense  and  fibrous  in  its  inner  part,  which  formed  the  anterior  wall  of  the  sac 
lined  by  the  amnion;  //,  wall  of  primary  tubal  gestation  sac,  within  which  are  the  pla- 
centa and  blood-clot ;  /,  umbilical  cord. 

the  various  portions  of  the  ovum.  The  blood  may  spread  in 
various  directions  from  the  original  site  of  the  hemorrhage — in 
some  cases  the  mass  may  increase  greatly  in  size  owing  to  suc- 
cessive outpourings  of  blood.  In  course  of  time  the  hematoma 
may  gradually  become  absorbed. 


VARIETIES  STUDIED   IN  DETAIL. 


401 


In  some  cases  infection  occurs,  suppuration  taking  place  in  the 
broad  ligament,  forming  a  pelvic  abscess  that  may  burrow  in 
various  directions,  and  may  escape  through  the  bowels,  bladder, 
vagina,  abdominal  wall,  perineum,  buttock,  or  groin  ;  in  the  ma- 
jority of  cases  opening  takes  place  into  the  bowel,  especially  the 
rectum  or  sigmoid  flexure.  The  discharge  may  continue  for  a  short 
or  long  time ;  in  some  cases  it  may  last  for  many  years.  Infection 
in  these  cases  almost  always  arises  from  the  bowel,  being  due  to 
the  slipping  upward  of  the  peritoneum  and  to  the  close  relation- 
ship that  is  established  between  the  gestation  sac  and  the  wall  of 
the  bowel. 

In  some  cases  mummification  of  the  fetus  may  occur,  though 
sometimes  it  may  be  transformed  into  adipocere  or  a  lithopedion. 


Fig.  148. — Transverse  section  across  pelvis  in  case  of  tuboperitoneal  gestation 
illustrated  in  Fig.  147:  a,  Right  acetabulum;  b,  symphysis;  c,  third  sacral  vertebra; 
d,  upper  end  of  bladder  above  its  cavity  ;  e,  uterus  displaced  backward  and  to  the  left ; 
/  placenta  and  blood  within  primary  tubal  sac  ;  g,  fibrin  ;  h,  peritoneal  cavity  lined 
with  amnion. 

3.  Cases  which  Rupture  into  the  Peritoneal  Cavity. — {a)  Tubo- 
peritoneai  Gestation. — In  this  form  the  fetus  escapes  in  its  mem- 
branes into  the  peritoneal  cavity,  the  placenta  remaining  in  the 
tube,  the  pregnancy  continuing  to  progress.  This  variety  was 
first  definitely  established  by  me  in  1892.  I  described  in  detail 
a  case  in  which  pregnancy  had -advanced  to  term;  the  fetus 
lay  in  the  amniotic  sac,  which  was  attached  to  the  peritoneum 
behind  the  stomach,  transverse  colon,  and  great  omentum.     The 

26 


402 


ECTOPIC  PREGNANCY. 


umbilical  cord  passed  into  the  greatly  enlarged  left  Fallopian 
tube,  which  lay  in  front  of  the  uterus,  extending  from  the  utero- 
vesical  pouch  to  the  level  of  the  fourth  lumbar  vertebra,  being 
to  a  large  extent  adherent  to  surrounding  structures.  The  pla- 
centa was  considerably  altered  by  blood-extravasation. 

{b)  Tennmation  of  Gestation. — In  the  majority  of  cases  in 
which  rupture  occurs  into  the  peritoneal  cavity  the  life  of  the 
fetus  comes  to  an  end,  and  the  mother's  life  is  endangered  by  the 
outpouring  of  blood  that  occurs. 

As  regards  the  most  favorable  tim.e  for  rupture,  statistics  show 
that  it  is   in  the   second,  third,  and  fourth   months  of  gestation. 


Fig.  149. 


-Rupture  into  the  peritoneal  cavity  of  an  early  tubal  pregnancy  (Martin  and 
Orthmann). 


The  factors  that  lead  to  rupture  are  thinness  of  the  tube-wall, 
accompanied  by  separation  of  its  muscle  bundles  ;  increase  in  the 
size  of  the  vessels  in  the  wall ;  sudden  changes  in  blood-pressure  ; 
sudden  changes  in  intra-abdominal  pressure,  such  as  are  produced 
by  blows,  falls,  strains,  etc. ;  hemorrhage  in  the  substance  of  the 
tube-wall  or  within  its  lumen.  The  nature  and  extent  of  the 
rupture  vary  greatly  in  different  cases.  It  may  be  of  considerable 
size  or  very  small,  and  may  be  round,  linear,  or  irregular.  'It  may 
be  found  in  the  non-placental  or  in  the  placental  part  of  the  wall 
or  may  involve  both  portions.  The  whole  ovum  or  part  of  it  may 
escape  through  the  rent.  Sometimes  it  is  arrested  as  it  attempts 
to  pass  through,  thus  blocking  the  opening  and  checking  the  hem- 


VARIETIES  STUDIED   IN  DETAIL. 


403 


orrhage.  Sometimes  the  internal  hemorrhage  may  be  so  great 
that  the  woman  dies  within  a  few  hours.  Parry  reports  1 1 3 
cases,  of  which  39  died  within  ten,  81  within  twenty-four,  and  98 
within  forty-eight,  hours.  Sometimes  the  primary  hemorrhage 
may  cease  and  may  be  followed  by  others  at  later  periods,  forming 
a  large  hematocele,  and  may  lead  to  the  death  of  the  woman. 
In  a  {q-vj  cases  recovery  occurs  spontaneously,  the  blood  and 
tissues  of  the  ovum  being  gradually  absorbed.  Sometimes  there 
may  be  considerable  peritonitis  in  connection  with  this  process. 
Occasionally  pus  formation  occurs  in  connection  with  a  hemato- 
cele. 

4.  The  Gestation  may  be  Destroyed  in  the  Tube. — {a)  By  the 
Oeenrrcnce  of  the  so-called  Tubal  Abortion. — This  consists  in  the 
detachment  of  the  ovum,  complete  or  partial,  from  the  tube-wall, 
accompanied  by  hemorrhage,  the  mass  gradually  escaping  through 
the  fimbriated  end  of  the  tube  into  the  peritoneal  cavity.  Some- 
times only  blood  escapes,  the  destroyed  ovum  remaining  in  the 
tube ;  in  some  cases  part  of  it  may  escape  with  the  blood. 


^ 

a             ^^———^ 

"~-^^     e                                           ■     . 

<^^  '"Mtj^ 

L~^ 

fj 

^1 

IB^ 

^^ 

"  /"^^^^ 

^^^^* 

0-^ 

^-^ 

Fig.  150. — Early  tubal  abortion.  The  tube  is  cut  longitudinally  (Orthmann):  e. 
Ovum  and  blood-clot  escaping  from  outer  end  of  tube  ;  t,  lumen  of  tube  near  uterus ; 
a,  a,  tube-lumen  near  ovum  ;  o,  ovary. 

Abortion  is  most  likely  to  occur  during  the  first  two  months 
of  pregnancy,  while  the  outer  end  of  the  tube  is  patent,  though  it 
may  also  occur  after  adhesions  have  closed  the  fimbriae.  The 
results  to  the  mother  are  practically  the  same  as  when  rupture  of 
the  tube-wall  occurs,  though  the  risk  to  her  life  is  not  at  all  so 
great,  the  escape  of  blood  being  usually  much  less  marked. 
In  19  cases  reported  by  Cullingworth  in  which  escape  took 
place  through  the  end  of  the  tube,  a  free  effusion  of  blood 
occurred  in  only  one  instance ;  in  the  majority  of  cases  a  local- 
ized pelvic  hematocele  was  formed. 

(b)  By  the  Formatio7i  of  a  Hematosalpinx. — The  tube  may  be 
distended  with  blood,  the  ovum  being  more  or  less  broken  up  and 
diffused  throughout  it. 


404 


ECTOPIC  PREGNANCY. 


{c)  By  the  Fori}iatio7i  of  a  Mole. — In  some  cases  hemorrhage 
occurs  in  the  placenta,  leading  to  death  of  the  ovum  and  forming 
a  mass  that  is  known  as  a  mole,  which  is  sometimes  expelled  into 
the  peritoneal  cavity,  but  may  remain  for  a  considerable  time  in 
the  tube,  slowly  shrinking  in  size. 

{d)  By  Suppuration. — The  contents  of  the  tube  may  sometimes 
become  infected,  leading  to  the  formation  of  a  pyosalpinx. 

{e)  In  Cases  in  whicli  Pregnancy  is  Considerably  Advanced. — 
Mummification  or  transformation  into  adipocere  or  a  lithopedion 
may  result. 

II.  Interstitial. — It  is  rare  that  an  ovum  develops  in  that  por- 
tion of  the  tube-wall  that  is  situated  in  the  uterine  wall.  In  early 
specimens  the  whole  uterus  appears  to  be  enlarged,  though  irregu- 


FlG.  151.— Right  interstitial  tubal  gestation  ruptured  into  the  peritoneal  cavity. 
gestation  sac  and  uterine  cavity  are  opened  from  behind  (Hennig). 


The 


larly.  The  gestation  grows  internal  to  the  round  ligament  on  the 
side  to  which  it  belongs — as  does  a  cornual  pregnancy.  As  the 
sac  enlarges  it  pushes  the  uterine  cavity  toward  the  opposite  side ; 
it  may  also  extend  outward  between  the  layers  of  the  broad  liga- 
ment, or  upward  toward  the  abdomen.  Sometimes  the  gestation 
may  extend  into  the  uterine  cavity.  As  development  continues 
some  part  of  the  uterine  musculature  surrounding  the  gestation 
becomes  very  thin. 

Rarely  may  an  interstitial  pregnancy  continue  to  full  time  ; 
rupture  usually  occurs.     When  this  is  intraperitoneal,  the  results 


VARIETIES  STUDIED   IN  DETAIL.  405 

are  fatal,  being  due  to  hemorrhage.  Rupture  between  the  layers 
of  the  broad  ligament  is  rare.  Sometimes  it  may  take  place 
into  the  uterine  cavity,  or  into  both  peritoneal  and  uterine  cav- 
ities. Very  rarely  the  fetus  may  die  in  advanced  gestation,  the 
ovum  remaining  i)i  situ. 

III.  Infundibular. — An  ovum  may  develop  in  the  outer  end  of 
the  Fallopian  tube,  though  not  frequently.  Cases  have  been  de- 
scribed as  "  tubo-ovarian  "  and  "  tubo-abdominal."  Owing  to  the 
mobility  of  the  outer  end  of  the  tube,  such  gestations  are  likely 
to  be  found  in  various  positions,  and  adhesion  may  form  between 
the  fimbriae  and  the  ovary,  broad  ligament,  parietes,  bowel,  blad- 


FlG.  152. — Tubo-ovarian  ectopic  gestation  rupture.  Second  month  (Martin  and 
Orthmann) :  ou,  Uterine  end  of  tube;  r,  site  of  rupture  in  tube-wall;/",  fimbriae;  e, 
blood-clot;  oz',  ovary  ;  /<?,  tubo-ovarian  cavity  opened. 

der,  etc.  The  gestation  sac  may  easily  rupture  and  the  ovum 
may  pass  into  the  peritoneal  cavity  or  elsewhere.  Sometimes  it 
may  extend  into  an  ovarian  sac  of  peritoneum  behind  the  broad 
ligament ;  sometimes  into  a  corpus  luteum  cavity  or  other  cyst 
of  the  ovary. 

IV.  Anomalous  Varieties. — Under  this  heading  may  be  in- 
cluded some  very  rare  forms  of  gestation  whose  development  is 
not  yet  well  ascertained.  It  has  been  shown  that  an  ovum  may 
become  attached  to  and  grow  in  an  accessory  tube,  an  accessory 
fimbriated  extremity,  and  in  a  tubal  diverticulum.  It  may  also 
develop  on  the  ovarian  fimbria  near  the  tube  or  near  the  ovary. 
In  this  category  must  be  placed  those  cases  described  as  "  ovarian 
pregnancy."  It  is  now  incontestable  that  a  gestation  may  be 
found  entirely  within  the  substance  of  the  ovary.  The  most 
thoroughly  described  specimens  are  those  of  Van  Tussenbroek  ^ 

'  Ann.  de  Gynec.  et  d' Obsid.,  Dec,  1899. 


406  ECTOPIC  PREGNANCY. 

and  J.  F.  Thompson.^  Regarding  the  original  place  of  embedding 
of  the  ovum  in  these  cases  we  are,  however,  in  doubt.  A  priori, 
there  is  a  strong  presumption  in  favor  of  believing  that  the  fer- 
tilized ovum  in  the  human  female  can  begin  its  development  only 
in  tissue  derived  from  the  Miillerian  tract.  This  view  is  not 
weakened  by  the  rare  finding  of  an  early  gestation  in  the  ovary, 
for  it  is  known  that  portions  of  tissue  derived  from  the  Miillerian 
tract  may  be  on  the  surface  of  the  ovary  or  in  its  substance.  It 
cannot,  therefore,  be  disproved  that  the  ovum  may  begin  its  de- 
velopment on  such  portions,  thereafter  extending  into  a  Graafian 
follicle,  a  cyst  in  the  ovary  or  the  ovarian  stroma,  just  as  an  early 
tubal  pregnancy  may  extend  into  the  broad  ligament  and  develop 
in  its  tissues. 

In  the  past  many  specimens  have  wrongly  been  described  as 
examples  of  ovarian  pregnancy  because  of  incomplete  examina- 
tion. Thus,  an  ovarian  hematoma  has  sometimes  been  so  termed. 
Pregnancy  in  an  accessory  tube,  in  an  accessory  fimbriated  end, 
or  in  a  tubal  diverticulum  may  easily  be  mistaken  for  an  ovarian 
gestation  when  it  is  intimately  blended  with  the  ovary  or  when  the 
ovary  is  congenitally  absent  on  the  side  of  the  gestation.  In  the 
same  way  error  may  easily  arise  when  the  ovum  develops  on  a 
fimbria  near  the  ovaiy.  A  broad-ligament  gestation  may  become 
so  related  to  the  ovary  that  the  latter  appears  to  be  part  of  the 
gestation  sac,  being  thinner  and  adherent,  so  that  it  cannot  be 
found  as  an  independent  structure.  If  in  such  a  condition  the 
outline  of  the  tube  be  distinguishable,  the  mistake  may  be  made  of 
describing  the  gestation  as  "  ovarian." 

V.  Cornual  Pregnancy. — Though  not  ectopic,  a  cornual  preg- 
nancy is  best  considered  in  this  connection  on  account  of  the  close 
resemblances  between  them.  When,  owing  to  maldevelopment  of 
the  Miillerian  tracts,  a  single  uterus  is  not  formed,  various  con- 
ditions of  the  bicornute  condition  may  be  produced.  To  one  of 
these  only  is  it  necessary  to  refer  here — viz.,  that  in  which  one 
horn  is  more  or  less  rudimentary.  This  imperfect  horn  may 
become  the  seat  of  a  pregnancy  whether  its  lumen  be  continuous 
with  that  of  the  well-formed  horn  or  whether  there  be  no  con- 
nection between  them.  In  the  latter  case  the  ovum  must  have 
been  fertilized  by  spermatozoa  that  passed  upward  along  the 
healthy  horn.  Such  cases  of  cornual  pregnancy  are  rare,  and  are 
apt  to  end  fatally  by  rupture  into  the  peritoneal  cavity,  generally 
after  the  third  month.  In  a  few  instances  the  ovum  has  ceased  to 
grow  without  the  occurrence  of  rupture. 

General  Considerations. — Changes  in  the  Ovum  after 
Death  when  it  is  Retained  in  situ  and  not  Absorbed  nor  Altered 
by  Suppuration. — Mummification  is  a  change  that  leads  to  the 
shrinkage  of  the  tissues  of  the  ovum  by  the  absorption  of  fluid 

^  A7ner.   Gynec,  July,  1902. 


DEVELOPMENTAL    CHANGES.  407 

from  them.  The  membranes  and  placenta  become  shriveled  and 
fibrous,  closely  enveloping  the  fetus,  which  is  also  much  shrunken. 
Sometimes  this  process  is  accompanied  by  calcareous  deposition. 

Adipocere  transformation  consists  in  an  alteration  of  the  tissues 
of  the  fetus  into  a  soap-like  substance  with  a  golden-yellow  tinge. 
The  bones  may  or  may  not  be  altered.  Sometimes  the  change  is 
accompanied  by  calcareous  deposits. 

Calcification  of  the  ovum  has  frequently  been  described  ;  the 
membranous  placenta  and  the  maternal  tissues  external  to  it  may 
alone  be  affected.  In  some  cases  also  the  fetus  may  be  calcified, 
the  salt  being  usually  deposited  superficially,  though  sometimes 
it  may  be  scattered  throughout  the  fetal  tissue.  Occasionally  the 
fetus  alone  may  be  the  seat  of  the  calcareous  change — lithopedion 
proper.  Sometimes  the  tissue  may  be  so  hard  as  to  resemble 
bone. 

Alleged  Grozvth  of  the  Placenta  after  Death  of  the  Fetns. — It 
has  been  held  by  many  that  the  placenta  may  continue  to  grow 
after  fetal  death  ;  this  view  is  erroneous.  There  may  be  an  in- 
crease in  size,  due  to  extravasation  of  the  maternal  blood  into  its 
substance  from  time  to  time,  but  the  villi  of  the  chorion  show  only 
degenerative  changes. 

Repeated  Ectopic  Gestation. — It  is  believed  that  ectopic  preg- 
nancy may  occur  more  than  once  in  the  same  tube ;  certainly  it 
is  well  established  that  having  occurred  in  one  tube  it  may  take 
place  at  a  later  period  in  the  other.  Cases  have  been  reported  in 
which  the  second  gestation  has  taken  place  while  remains  of  the 
first  have  been  present  in  the  tube. 

Plnral  Ectopic  Gestation. — Rarely  the  gestation  may  occur  in 
each  tube  at  the  same  time,  or  two  ova  may  develop  at  the  same 
time  in  different  parts  of  the  same  tube,  or  a  twin  pregnancy  may 
develop  in  one  tube. 

Concnrrent  Ectopic  and  Uterine  Gestation. — Sometimes  ectopic 
and  uterine  gestation  may  take  place  concurrently.  There  is  no 
evidence  that  a  pregnancy  may  develop  in  the  uterus  after  an 
ectopic  pregnancy  has  started  to  develop,  or  as  long  as  its  de- 
velopment continues.  After  an  ectopic  gestation  has  ceased  to 
develop,  however,  whether  the  ovum  has  been  absorbed  or  not, 
pregnancy  may  take  place  in  the  uterus. 

Developmental  Changes. — Muscular  Part  of  the  Tube-wall. — 
There  is  little  doubt  that  the  development  of  a  gestation  in  the 
tube  induces  changes  in  its  musculature  similar  to  those  that  take 
place  in  the  uterus  during  normal  pregnancy,  hypertrophy  and 
hyperplasia  of  its  fibers  occurring.  These  changes  are  chiefly 
marked  through  the  first  two  or  three  months,  but  very  slightly 
afterward,  the  muscle  after  an  early  period  being  unable  to  respond 
to  the  rapid  development  of  the  ovum  as  does  that  of  the  normal 
fruit-holder — the  uterus  ;  the  connective  tissue,  however,  increases 


408  ECTOPIC  PREGNANCY. 

considerably.  The  muscle  bundles  become  thinned,  stretched, 
separated,  and  irregularly  distributed.  After  the  early  months 
large  portions  of  the  wall  may  be  found  in  which  no  muscle  is 
distinguishable. 

Miico2(s  Menibraiic. — Different  opinions  are  held  in  regard  to 
the  changes  in  the  tubal  mucosa.  It  has  been  stated  by  some  that 
no  decidual  transformation  takes  place ;  this  view  is  erroneous. 
Careful  study  will  usually  reveal  the  presence  of  decidual  cells, 
though  they  may  frequently  be  scanty  or  irregularly  distributed 
They  are  best  studied  in  the  early  months  of  ampullar  tubal 
gestation.  In  advanced  stages,  after  the  mucosa  has  been  greatly 
stretched  and  thinned,  the  decidual  cells  are  relatively  few  and 
scattered,  though  in  parts  they  may  be  abundant.  When  the  tube 
bursts  and  the  ovum  develops  in  the  broad  ligament,  decidual 
cells  are  not  usually  found  in  non-tubal  tissues,  even  though  they 
be  in  relation  to  the  placenta.  When  the  ovum  develops  on  a 
fimbria  or  other  small  portion  of  the  Mijllerian  tract,  there  must 
necessarily  be  very  little  decidual  tissue ;  and  if  the  pregnancy 
develops  in  the  midst  of  the  ovary,  no  decidual  cells  may  be  found 
after  an  early  period.  The  decidual  reaction,  as  it  usually  occurs 
in  tubal  gestation,  may  be  described  as  analogous  to  that  which 
occurs  in  the  uterus  in  the  formation  of  a  decidua  vera.  The  re- 
semblance to  the  arrangement  of  the  uterine  vera  may  sometimes 
be  very  close.  There  is,  however,  no  uniformity  in  its  production. 
Sometimes  an  extensive  portion  of  the  mucosa  may  be  altered ; 
sometimes  only  a  limited  portion  arranged  circularly  or  on  one 
side.  In  some  cases  a  superficial  compact  and  deep  spongy  layer 
may  be  distinguished.  This  arrangement  may  be  due  to  a  blend- 
ing of  adjacent  portions  of  the  original  mucosal  fringes  near  the 
tube-lumen,  the  spaces  between  them  resembling  the  gland  spaces 
of  the  normal  uterine  mucosa.  Sometimes  the  tubal  mucosa, 
especially  near  the  uterus,  may  considerably  resemble  the  uterine 
mucosa ;  in  such  a  condition  there  will  be  resemblances  after  de- 
cidual transformation.  As  the  decidual  changes  progress  the 
lining  epithelium  becomes  flattened,  broken,  and  degenerated. 
Many  connective-tissue  cells  are  transformed  into  large  decidual 
cells  somewhat  similar  to  those  found  in  the  uterus,  the  most 
marked  development  taking  place  nearest  the  tube-lumen.  The 
epithelium  covering  the  mucosal  folds  near  the  musculature  tends 
to  become  disintegrated  and  cast  off  The  blood-vessels  increase 
in  size,  the  capillaries  here  and  there  dilating  to  form  small 
sinuses. 

Decidua  Scrotma. — That  part  of  the  mucosa  to  which  the  ovum 
becomes  attached  may  be  termed  the  decidua  serotina.  Its  con- 
dition at  the  time  of  the  embedding  of  the  ovum  has  not  been 
described.  No  tubal  pregnancy  has  been  described  as  early  as  the 
uterine  pregnancy  described  by  Hubert  Peters.     In  the  earliest 


DEVELOPMENTAL    CHANGES.  4O9 

specimens  described  changes  are  found  somewhat  similar  to  those 
noted  in  the  uterus  in  normal  pregnancy.  The  blood-vessels  are 
dilated,  the  capillaries  being  distended  to  form  large  sinuses  in  the 
superficial  portion  of  the  decidua.  The  connective  tissue  shows 
hypertrophy  and  hyperplasia  of  the  cells,  leading  to  the  formation 
of  characteristic  decidual  cells,  which  is  most  advanced  near  the 
surface. 

As  pregnancy  continues  the  cells  tend  to  lie  with  their  long 
axes  parallel  to  the  surface,  due  probably  to  the  increasing  pressure 
of  the  growing  ovum.  Degeneration  also  takes  place  in  the  cell- 
substance  and  nucleus.  In  many  parts  their  outlines  may  become 
very  indefinite.  A  form  of  coagulation-necrosis  occurs,  areas  of 
the  tissue,  having  a  fibrinous  or  hyaline  appearance  under  the 
microscope.  Of  special  interest  is  the  occasional  proliferation  of 
the  endothelium  in  some  of  the  large  sinuses,  forming  a  layer  of 
several  thicknesses  of  cells,  which  in  some  instances  may  extend 
somewhat  into  the  surrounding  decidual  tissue.  This  has  not 
been  observed  in  uterine  pregnancy,  but  has  been  observed  in  the 
hedge-hog  by  Hubrecht. 

The  arteries  and  veins  present  appearances  similar  to  those 
found  in  the  decidua  of  uterine  pregnancy. 

Decidua  Reflexa. — There  has  been  much  dispute  as  to  the 
formation  of  a  reflexa  in  tubal  pregnancy.  Some  deny  its  ex- 
istence ;  others,  while  admitting  that  it  may  be  present,  express 
different  views  as  regards  its  formation.  Owing  to  the  smallness 
of  the  tube  it  is  probable  that  in  some  cases  a  distinct  reflexa  may 
never  be  able  to  form,  the  gap  formed  in  the  mucosa  by  the  em- 
bedding of  the  ovum  being  closed  by  the  opposite  side  of  the  tube  ; 
in  some  cases  a  reflexa  may  be  partially  formed,  blending  imme- 
diately with  the  adjacent  mucosa  lining  the  tube.  That  the  com- 
plete reflexa  may  be  formed  cannot  be  denied,  for  specimens  have 
been  described.  It  has  a  structure  similar  to  that  of  the  neigh- 
boring serotina.  Degeneration  takes  place  in  it  very  rapidly, 
and  there  is  a  great  tendency  to  rupture  of  blood-vessels  in  its 
substance. 

When  the  ovum  is  not  early  destroyed,  the  reflexa  becomes 
stretched  and  thinned  and  pressed  against  the  surrounding  portion 
of  the  wall  of  the  tube,  gradually  disappearing. 

Relations  between  Oviun  and  Decidua. — The  relationships  be- 
tween the  ovum  and  decidua  in  tubal  pregnancy  have  not  been 
described  at  such  an  early  date  as  in  the  case  of  uterine  pregnancy, 
but  the  information  given  by  many  preparations  within  the  first 
month  of  gestation  and  later  suggests  strongly  that  in  the  begin- 
ning the  conditions  are  similar  to  those  found  in  uterine  gestation. 
The  surface  of  the  serotina  next  to  the  ovum,  forming  the  maternal 
boundary  of  the  intervillous  spaces,  is  somewhat  irregular.  By 
the  end  of  the  first  month  a  thin  layer  of  hyaline  degeneration  is 


4IO  ECTOPIC  PREGNANCY. 

usually  present  near  the  surface.  Masses  of  syncytium,  varying 
in  shape  and  size,  are  attached  to  the  surface  ;  in  some  parts  the 
syncytium  forms  a  distinct  layer.  Below  the  surface  portions 
extend  in  various  directions,  even  into  the  musculature  of  the 
tube-wall.  They  may  also  extend  into  the  blood-sinuses  in  the 
decidua,  and  portions  may  be  carried  away  in  the  veins. 

The  maternal  blood-sinuses  communicate  with  the  intervillous 
space  by  openings  of  various  sizes,  and  occasionally  syncytium 
is  seen  in  the  process  of  absorbing  the  decidual  tissue  between  the 
sinus  and  the  surface  of  the  decidua. 

CJiorlon. — A  detailed  description  of  the  chorion  is  unnecessary, 
since  it  is  identical  with  that  which  has  already  been  given  in  the 
description  of  uterine  pregnancy.  The  villi  are  attached  to  the  ser- 
otina  and  the  reflexa  in  the  same  manner.  Great  variations  are 
found  as  regards  the  extent  of  degenerative  changes  in  the  early 
villi,  leading  to  atroph}'  and  disappearance.  In  some  cases  these 
correspond  to  the  changes  found  in  uterine  pregnancy,  for  the 
chorion  may  become  differentiated  into  a  placental  and  a  non- 
placental  portion ;  and  in  such  cases  the  placenta  may  have  a 
typical  discoid  shape.  Much  more  frequently  there  is  irregularity 
of  chorionic  dexelopment.  Sometimes  the  greater  part  of  the  villi 
may  remain  functional,  forming  a  placenta  that  in  the  early  preg- 
nancy fills  almost  the  entire  cavity  in  which  the  ovum  develops. 
Sometimes  the  placenta  may  have  an  irregular,  ring-shaped  char- 
acter. 

Anniioji. — The  amnion  is  the  same  as  that  found  in  uterine 
gestation. 

Tubal  Mjicosa  Outside  of  the  Sac  containing  tlie  Ovnin. — Great 
variations  are  found  in  this  part  of  the  mucosa.  Decidual  cells 
may  be  present  in  more  or  less  of  its  extent,  though  as  pregnancy 
advances  they  tend  to  disappear. 

Blood  is  frequently  found  in  this  part  of  the  lumicn,  and  may 
cause  considerable  flattening  of  the  mucosal  folds  against  the 
wall  or  may  mass  them  in  irregular  heaps.  As  the  gestation  in- 
creases more  of  the  tube  is  occupied,  and  the  mucosal  folds  ex- 
ternal to  the  sac  become  greatly  altered,  the  epithelium  becoming 
somewhat  flattened  and  frequently  cast  ofi". 

Symptoms  and  Signs. — Those  Due  to  the  Pregnancy  per 
se. — Sometimes  they  may  be  the  same  as  those  of  normal  preg- 
nancy, the  ectopic  gestation  reaching  an  advanced  stage,  being 
regarded  as  a  normal  uterine  pregnancy  both  by  the  woman  and 
her  physician.  Such  cases  are,  however,  very  rare.  In  the  great 
majority  of  instances  there  are  variations,  both  in  signs  and  symp- 
toms, which  are  suggestive  of  an  abnormal  condition,  though  there 
are  no  subjective  symptoms  of  such  marked  character  as  may  in- 
dicate to  the  woman  the  peculiar  nature  of  her  condition.  With 
regard  to  physical  examination,  it  may  be  said  that  there  are  very 


MENSTRUATION— CHANGES  IN   THE   BREASTS.  4I I 

few  cases  in  which  a  thorough  study  should  not  enable  the  phy- 
sician to  suspect,  if  not  to  establish,  the  character  of  the  gesta- 
tion. The  constitutional  and  sympathetic  changes  occur  with 
great  variations.  While  these  may  be  as  well  marked  as  in  normal 
labor,  they  are  frequently  less  distinct.  The  breasts,  for  example, 
in  ectopic  pregnancy  may  at  the  fourth  month  present  very  little 
pigmentation,  enlargement,  or  colostrum  formation.  The  dis- 
coloration of  the  vagina  is  frequently  slightly  marked.  It  must  be 
remembered,  however,  that  such  peculiarities  may  occasionally  be 
found  in  uterine  pregnancy. 

Menstruation. — Great  variations  are  found  as  regards  the 
menstrual  function.  It  may  cease  entirely  in  a  number  of  cases 
throughout  pregnancy;  it  may  take  place  regularly  for  the  first 
few  months  and  not  afterward ;  it  may  be  regular  at  first  and  then 
irregular ;  or  it  may  occur  at  irregular  intervals  throughout  preg- 
nancy. The  amount  of  blood  also  varies  greatly  ;  sometimes  the 
flow  may  consist  of  only  a  few  drops  ;  sometimes  it  may  last  for 
one  or  more  weeks.  In  some  cases  there  is  considerable  pain  in 
the  region  of  the  uterus  in  connection  with  the  periods,  but  in 
other  cases  there  may  be  little  or  no  suffering. 

Periodic  Colicky  Pains. — Such  pains  are  frequently  experi- 
enced, especially  after  the  second  month,  though  in  some  cases 
they  are  entirely  absent.  The  intervals  between  them  vary  con- 
siderably. Each  attack  consists  of  irregular,  intermittent  pains, 
felt  in  the  region  of  the  gestation  or  in  the  lower  abdomen.  The 
explanation  of  these  pains  has  been  a  matter  of  some  difference 
of  opinion.  They  are  believed  to  be  due  to  contractions  of  the 
gestation  sac  or  of  the  uterus.  It  is  probable  that  they  cannot  be 
caused  by  the  former  after  the  early  months,  because  of  the  rela- 
tively small  amount  of  muscular  tissue  in  the  wall.  Hemorrhage 
in  the  wall  of  the  tube  or  in  the  lumen  probably  explains  the  pain 
in  many  cases.  In  other  instances  it  is  possible  that  inflammatory 
changes  cause  the  disturbance. 

With  regard  to  the  uterus,  there  can  be  no  doubt  that  con- 
tractions in  its  musculature  are  frequently  present.  Sometimes 
they  are  marked,  and  indicate  the  efforts  of  the  organ  to  expel 
the  decidua  that  lines  it. 

Discharge  of  tlie  Uterine  Decidua. — Very  frequently  portions 
of  the  lining  of  the  uterine  mucosa  are  expelled  with  more  or  less 
blood  during  the  course  of  an  ectopic  pregnancy,  often  with  much 
uterine  pain.  Sometimes  a  complete  cast  of  the  uterine  cavity 
may  be  shed.  This  tissue  presents  characteristic  changes  similar 
to  those  found  in  the  decidua  vera  in  normal  uterine  pregnancy. 

Changes  in  the  Breasts. — Mammary  changes,  while  similar 
to  those  found  in  normal  pregnancy,  are,  as  a  rule,  not  so  pro- 
nounced. If  the  gestation  comes  to  an  end,  retrogressive  altera- 
tions  occur,  though   sometimes,  when   cases   reach  full  term  and 


412  ECTOPIC  PREGNANCY. 

undergo  a  spurious  labor  accompanied  by  the  death  of  the  fetus, 
increased,  secretion  of  milk  may  occur. 

Abdominal  Enlargement. — In  uterine  gestation,  after  the  third 
month,  there  is  a  fairly  constant  progressive  rate  and  form  of 
increase  in  the  size  of  the  abdomen ;  in  ectopic  gestation  there  is 
less  uniformity.  The  more  advanced  the  gestation,  the  more  do 
the  abdominal  swellings  in  the  different  ectopic  varieties  tend  to 
resemble  one  another,  and  the  shape  of  the  abdomen  may  resemble 
considerably  that  found  in  normal  cases.  In  the  majority  of 
instances,  however,  the  increase  of  the  abdomen,  especially  during 
the  first  five  or  six  months,  is  mainly  one-sided.  Frequently  a 
tubal  pregnancy  growing  in  one  side  and  not  falling  below  the 
pelvic  brim  may,  within  the  first  three  months,  form  a  swelling  in 
the  iliac  region,  noticeable  to  the  woman  or  to  others.  Many 
cases,  however,  form  no  apparent  swelling  above  the  brim  until 
they  have  developed  to  a  great  extent  below  it.  Those  cases 
which  rupture  into  the  broad  ligament  and  develop  upward  are 
particularly  liable  to  be  noticed  as  irregular  lateral  swellings. 

Fetal  Movements. — Fetal  movements  are  felt  by  the  mother 
first  usually  between  the  fourth  and  fifth  months,  as  in  normal 
pregnancy,  variations  being  found  ;  in  a  number  of  cases  they 
may  be  felt  earlier  and  more  distinctly  than  in  normal  uterine 
pregnancy,  probably  owing  to  the  greater  thinness  of  the  gesta- 
tion sac.  Frequently  the  movements  are  felt  first  on  one  side. 
In  early  ectopic  sacs  that  lie  close  to  the  abdominal  wall  they 
may  frequently  be  detected  by  auscultation  before  the  mother  feels 
them,  and  more  readily  than  in  uterine  pregnancy.  After  midterm 
they  may  often  be  felt  and  heard  with  very  great  distinctness  if 
the  intestines  do  not  intervene  between  the  gestation  sac  and  the 
anterior  abdominal  wall.  When  fetal  heart-sounds  are  heard,  they 
may  appear  unusually  distinct,  though  there  are  great  variations, 
according  to  the  health  of  the  fetus,  its  position,  and  other  factors. 

Maternal  Souffle. — The  souffle  may  frequently  be  heard  in 
one  or  both  iliac  regions,  great  variations  being  found.  It  may 
be  absent,  faint,  or  very  loud.  It  is  most  pronounced  close  to  the 
gestation  sac. 

Changes  in  the  Vagina. — The  walls  of  the  vagina  become 
soft,  lax,  and  dark  in  color,  as  in  normal  pregnancy,  though  these 
changes  are  not  usually  so  pronounced. 

Changes  in  the  Uterus. — The  cervix  becomes  somewhat  soft- 
ened and  darker  in  color,  though  not  usually  to  the  extent  found 
in  uterine  pregnancy.  The  whole  organ  enlarges,  the  extent 
varying  in  different  cases.  It  retains  the  non-pregnant  shape,  and 
the  body  does  not  become  rounded  as  in  normal  pregnancy,  nor 
does  any  special  softening  occur  above  the  cervix.  The  latter 
frequently  becomes  patulous,  especially  during  the  periods  of 
contractions  in  the  organ.     Bandl  has  stated  that  uterine  enlarge- 


SYMPTOMS  AND   SIGNS  DUE    TO    COMPLICATIONS.       413 

ment  is  greater  the  nearer  to  the  organ  the  ovum  is  developed. 
In  the  majority  of  cases  it  is  between  4  and  5  in.  in  length  ;  some- 
times, however,  it  may  be  as  much  as  7  or  8  in.  The  mucosa  shows 
marked  alterations  similar  to  those  found  in  the  decidua  vera  of 
normal  uterine  pregnancy.  These  changes  are  constant ;  some- 
times, however,  on  examining  the  interior  of  the  uterus,  no  decidual 
tissue  may  be  found,  owing  to  its  previous  expulsion. 

Phenomena  Noted  at  Full  Time. — When  an  ectopic  gestation 
advances  to  full  term  there  usually  occurs  what  has  been  termed 
a  spurious  labor,  characterized  by  the  occurrence  of  a  series  of 
pains  resembling  those  of  normal  labor.  A  number  of  cases  are 
on  record  where  the  patient  has  been  attended  under  such  circum- 
stances in  the  belief  that  normal  labor  was  taking  place.  Some- 
times these  pains  develop  prematurely  during  the  seventh  or 
eighth  month.  The  duration  of  the  spurious  labor  varies  :  it  may 
last  hours  or  even  days.  When  the  pains  once  cease,  there  is  usu- 
ally no  return,  though  sometimes  there  may  be.  There  has  been 
some  difference  of  opinion  as  regards  the  cause  of  these  pains. 
There  can  be  little  doubt  but  that  they  are  due  to  uterine  con- 
tractions. The  gestation  sac  can  take  no  part  in  their  production 
except  in  the  case  of  an  interstitial  pregnancy  or  possibly  a  cor- 
nual  pregnancy. 

The  pains  are  accompanied  by  dilatation  of  the  cervix,  by 
expulsion  of  mucus,  and  frequently  blood  and  decidual  tissue. 

The  fetus  probably  always  dies  at  the  time  of  spurious  labor, 
though  it  is  possible  it  may  occasionally  live  to  a  later  period. 
Voluntary  straining-efforts  are  frequently  made  by  the  patient 
during  the  pains,  and  this  may  cause  separation  of  the  placenta, 
leading  to  death  of  the  fetus.  After  the  death  of  the  fetus  the 
abdomen  usually  diminishes  somewhat  in  size,  the  liquor  amnii 
becoming  absorbed.  If  the  fetus  is  not  removed,  it  may  become 
enveloped  in  placenta  and  membranes,  and  may  undergo  one  or 
other  of  the  changes  that  have  already  been  described.  In  some 
cases  the  amniotic  fluid  slowly  diminishes,  but  it  may  occasionally 
increase. 

Symptoms  and  Signs  due  to  Complications.— Pressure 
Effects. — Displacement  of  the  bladder  may  take  place  in  various 
directions  and  the  various  well-known  disturbances  of  micturition 
may  result. 

In  the  early  months  there  is  trouble  when  the  gestation  sac 
falls  on  the  bladder  or  behind  the  uterus  ;  in  the  latter  position  its 
growth  leads  to  pressure  of  the  former  against  the  pubes.  In 
extraperitoneal  development  the  ovum  may  come  into  close  rela- 
tionship with  the  bladder-wall.  The  ureters  may  also  be  inter- 
fered with  and  the  renal  functions  thereby  altered.  Pressure  on 
the  rectum  is  apt  to  lead  to  constipation ;  diarrhea  may  also  be 
caused.     Interference  with  vessels  may  lead  to  edema  or  varicosity 


414  ECTOPIC  PREGNANCY. 

of  the  external  genitals  or  of  the  extremities.     Pressure  on  nerves 
may  also  lead  to  pain  in  the  pelvis,  lower  extremities,  and  muscles. 

Peritonitis. — Acute  peritonitis  is  veiy  rare  in  ectopic  preg- 
nancy. It  may  sometimes  follow  rupture  of  the  tube  into  the 
abdomen,  or  may  follow  septic  changes  in  the  gestation  sac  with 
invasion  of  the  peritoneum.  Chronic  peritonitis  is  frequently  found, 
causing  changes  in  the  wall  of  the  gestation  sac  and  leading  to 
adhesions  between  it  and  the  surrounding  structures.  In  the 
majority  of  cases  this  is  merely  the  continuance  of  an  inflammatory 
process  that  existed  before  the  pregnancy. 

Pain. — Various  forms  of  pain  are  found  in  ectopic  pregnancy. 
Those  of  a  somewhat  labor-Hke  character  that  occur  at  intervals 
have  already  been  described.  Suffering  may  also  occur  from  me- 
chanical pressure  of  the  gestation  sac  on  nerves  in  the  pelvis  and 
abdomen,  and  may  also  be  caused  by  vigorous  movements  of  the 
fetus  in  the  advanced  months.  Reference  has  already  been  made 
to  pains  that  occur  in  connection  with  spurious  labor.  Peritonitis 
may  in  some  cases  lead  to  suffering,  but  in  many  cases  it  is  not 
marked  by  any  pain  whatever.  Rupture  of  the  gestation  sac  into 
the  broad  ligament  or  into  the  peritoneal  cavity  may  often  be  asso- 
ciated with  pain,  though  in  some  cases  it  is  slight  or  absent. 
Hemorrhage  into  the  gestation  sac  may  also  cause  distress. 

Phenomena  Accompanying  Hemorrhage. — The  symptoms  of 
hemorrhage  in  connection  with  ectopic  pregnancy  vary  greatly, 
depending  upon  the  size  and  site  of  the  hemorrhage.  In  cases  of 
great  loss  of  blood  there  are  symptoms  of  shock  and  acute  anemia. 
Pain  may  be  present,  vaiying  greath^  in  various  cases.  When  a 
hematocele  or  hematoma  is  formed,  \arious  pressure  effects  may 
follow — i.e.,  interference  with  the  functions  of  the  rectum,  ureters, 
bladder,  etc. 

Infection. — When  septic  micro-organisms  invade  an  ectopic 
pregnancy,  various  changes  may  be  produced  that  are  found  in 
septic  processes  occurring  apart  from  pregnancy.  Suppuration, 
leading  to  the  formation  of  a  collection  of  pus,  runs  the  same 
course  as  in  other  pelvic  or  abdominal  abscesses. 

Interference  with  the  Digestive  Tract. — Pressure  on  the 
rectum  has  already  been  described.  As  a  result  of  chronic  peri- 
tonitis, leading  to  adhesions  among  the  intestines,  there  may  be 
the  ordinary  disturbances  associated  with  that  complication  when 
pregnancy  is  not  present.  When  the  gestation  reaches  an  ad- 
vanced period,  the  most  marked  alimentaiy  disturbances  are  likely 
to  be  found,  though  they  occur  with  many  variations ;  in  some 
instances  there  may  be  very  little  disturbance  in  connection  with 
either  the  stomach  or  the  intestines. 

Rupture  of  the  Gestation  Sac. — The  symptoms  and  signs 
following  rupture  of  the  gestation  sac  vary  greatly.  They 
depend  mainly  upon  the  nature  of  the  rupture,  the  site  of  the 


DIAGNOSIS.  415 

rupture  and  the  amount  of  blood  lost,  the  complication  of 
infection,  etc. 

At  the  time  of  spurious  labor  the  sac  may  sometimes  burst. 
Rarely  does  this  take  place  so  that  the  fetus  escapes  into  some 
part  of  the  peritoneal  cavity  or  into  the  vagina.  Sometimes  it  may 
enter  the  large  intestine.  An  interstitial  pregnancy  may  burst 
into  the  uterine  cavity.  When  suppuration  occurs,  the  fetal  tissues 
may  escape  by  the  bowel,  bladder,  vagina,  or  parietes. 

Changes  Following  Death  of  the  Fetus. — If  the  maternal 
souffle  has  been  present,  it  gradually  disappears.  Labor-like  pains^ 
may  occur  ;  sometimes  also  at  later  periods.  Menstruation  usually 
returns,  though  not  in  any  definite  or  regular  manner.  The  abdo- 
men usually  diminishes  in  size,  though  in  some  cases  it  may 
not  change  much.  If  no  suppuration  occurs,  the  mass  may  be 
carried  for  many  years  and  cause  little  or  no  trouble  to  the  woman. 

Diagfnosis. — The  difficulty  of  establishing  an  accurate  diag- 
nosis in  ectopic  gestation  is  largely  due  to  the  great  variations  in 
the  signs  and  symptoms  that  may  be  present.  In  studying  any 
given  case  it  is  necessary  to  prove  that  the  uterus  is  not  gravid, 
that  an  abnormal  swelling  exists,  and  that  it  is  due  to  the  ectopic 
development  of  an  ovum.  The  most  important  factor  in  establish- 
ing the  diagnosis  is  the  physical  examination  of  the  pelvis  and 
abdomen,  especially  by  abdominorectovaginal  bimanual  method. 

An  anesthetic  should  always  be  employed  when  there  is  un- 
certainty. The  great  difference  between  uterine  and  ectopic  preg- 
nancy is  that  the  physical  changes  in  the  abdomen  and  pelvis 
occur  fairly  uniformly  in  the  former  and  with  great  variability  in 
the  latter. 

Relaxation,  softening,  and  discoloration  of  the  walls  of  the 
vagina,  though  usually  present,  are  often  not  very  well  marked. 
They  are  most  developed  in  cases  of  advanced  pregnancy.  In- 
creased pulsation  of  vessels  as  found  in  vaginal  examination  occurs 
with  great  variability.  The  shape  and  position  of  the  vagina  are 
altered  in  different  ways.  Sometimes  there  is  little  change ;  some- 
times there  is  marked  shortening,  especially  when  the  uterus  is 
pushed  downward  by  the  gestation  sac.  There  may  be  marked 
displacement  forward,  backward,  or  laterally.  The  position  of  the 
uterus  is  likewise  subject  to  many  alterations.  In  the  early  months 
it  may  not  be  much  changed  ;  later  it  is  frequently  pushed  upward 
and  forward  or  displaced  laterally ;  occasionally  it  is  pushed 
directly  downward,  or  may  be  retroposed  or  retroverted.  It  may 
occasionally  be  considerably  rotated.  Changes  in  its  size  have 
already  been  noted,  though  frequently  it  is  impossible  to  measure 
the  organ  owing  to  the  impossibility  of  outlining  its  upper  end. 
A  sound  must  never  be  used  when  there  are  doubts  as  regards  the 
existence  of  uterine  gestation.  When  the  uterus  can  be  entirely  pal- 
pated, it  does  not  present  the  alteration  found  in  normal  pregnancy. 


4l6  ECTOPIC  PREGNANCY. 

It  is  firmer  and  does  not  become  especially  soft  above  the  cervix. 
In  some  cases  it  may  be  felt  to  be  distinct  from  the  gestation  sac  ;  in 
others  it  is  so  related  to  it  that  it  appears  to  be  only  a  firm  portion 
of  its  wall.  In  other  cases  it  is  so  incorporated  that  it  cannot  be 
felt  in  any  way  distinct  from  it.  In  some  cases  when  bimanual 
examination  is  employed  fluctuation  may  be  obtained  in  the  liquor 
amnii,  ballottement  may  be  found,  and  the  fetal  movements  may 
be  felt.  In  other  cases  it  is  impossible  to  determine  these  points, 
owing  to  the  thickness  of  the  placenta  and  the  presence  of  ex- 
travasated  blood  or  other  complications. 

Various  conditions  must  be  considered  in  estabhshing  the 
diagnosis  of  ectopic  pregnancy. 

1.  Uterine  Pregnancy. — In  the  early  weeks  of  normal  preg- 
nancy a  pelvic  swelling  lying  alongside  the  uterus  may  be  regarded 
as  an  ectopic  sac,  the  enlargement  of  the  uterus  being  attributed 
to  the  influence  of  the  former.  If  the  uterus  had  formerly  been 
hardened  by  chronic  metritis,  the  mistake  is  more  liable  to  be  made, 
but  it  is  especially  when  there  is  some  irregularity  in  the  ordinary 
signs  and  symptoms — i.  c,  a  discharge  of  blood  from  the  uterus — 
that  the  risk  of  making  a  mistake  is  greatest. 

In  advanced  uterine  pregnancy  error  may  be  made,  especially 
when  the  wall  of  the  uterus  is  thin  and  the  liquor  amnii  scanty, 
allowing  the  fetal  parts  to  be  easily  palpated.  Error  may  also  be 
made  when  the  uterus  is  displaced  markedly  to  one  side  by  old 
adhesions,  by  a  tumor,  or  by  a  loaded  portion  of  bowel.  It  may 
also  occur  when  there  is  a  fibroid  tumor  in  the  wall  of  the  uterus. 

Ectopic  gestation  may  also  be  mistaken  for  uterine  pregnancy, 
especially  in  the  advanced  months,  though  an  interstitial  gestation 
might  be  mistaken  during  any  month.  In  some  cases  error  may 
be  made  even  after  the  most  careful  examination. 

2.  Retroversion  of  the  Gravid  Uterus. — Ectopic  pregnancy 
has  often  been  mistaken  for  this  condition,  chiefly  in  the  early 
months.  The  error  should  rarely  be  made  if  a  thorough  anesthetic 
examination  is  carried  out.  Similarly,  retroversion  of  the  preg- 
nant uterus  has  been  mistaken  for  ectopic  pregnancy.  It  is 
important  to  note  the  following  symptoms  and  signs  resulting 
from  pressure  of  the  displaced  gravid  uterus — viz.,  difficulty  in 
micturition,  retention  of  urine,  overdistention  of  the  bladder,  con- 
stipation, and  pains  in  the  pelvis  and  thighs.  If  the  bladder  be 
overdistended,  it  is  felt  as  a  round  or  oval  tumor  above  the  sym- 
physis. The  cervix  uteri  is  generally  close  behind  the  latter. 
The  body  of  the  uterus  is  felt  as  a  soft  cystic  swelling  in  the 
pouch  of  Douglas,  continuous  with  the  cervix. 

3.  Sacculation  of  the  Uterus. — When  sacculation  of  the 
anterior  or  posterior  wall  of  the  uterus  occurs,  with  displacement 
of  the  cervix,  the  condition  may  exactly  resemble  an  ectopic 
gestation. 


■  DIAGNOSIS.  417 

4.  Tumor  of  the  Ovary. — This  may  be  mistaken  for  ectopic 
pregnancy  under  various  circumstances.  A  small  tumor  develop- 
ing in  the  pelvis  or  burrowing  beneath  the  broad  ligament,  dis- 
placing the  uterus,  may  simulate  the  condition.  When  there  is 
a  large  tumor,  error  may  be  made  if  the  uterus  be  adherent  to  it, 
especially  if  there  be  a  history  of  irregular  menstruation,  accom- 
panied by  some  of  the  minor  signs  and  symptoms  of  pregnancy. 
Torsion  of  the  pedicle  may  result  in  many  of  the  signs  and  symp- 
toms associated  with  rupture  of  blood-vessels  in  an  ectopic  sac. 
When  uterine  pregnancy  is  complicated  with  an  ovarian  tumor,  an 
error  in  diagnosis  is  very  apt  to  arise.  A  tumor  associated  with  a 
uterus  from  which  an  incomplete  early  abortion  has  passed  may  be 
difficult  to  diagnose  from  ectopic  gestation. 

5.  What  has  been  said  of  ovarian  cysts  applies  to  other  pelvic 
swellings — /.  e.,  those  arising  in  the  tube  or  broad  ligaments. 

6.  Fibromyomatous  or  Fibrocystic  Tumors. — Ordinary  fibroid 
tumors  are  generally  easily  distinguished  from  ectopic  pregnancy. 
Sometimes  an  intramural  growth  may  simulate  markedly  an  in- 
terstitial gestation.  A  large  irregular  fibroid  mass  may  sometimes 
be  mistaken  for  an  ectopic  gestation  that  has  reached  an  advanced 
period.  Death  of  the  fetus  then  occurs,  followed  by  absorption 
of  the  liquor  amnii.  Occasionally  the  occurrence  of  a  local  peri- 
tonitis in  connection  with  a  fibroid  uterus  may  simulate  an  ectopic 
pregnancy  in  which  rupture  has  occurred. 

7.  Pelvic  Hematocele  and  Hematoma. — The  occurrence  of 
an  outpouring  of  blood  in  the  peritoneal  cavity  or  the  cellular 
tissue  of  the  pelvis  apart  from  ectopic  pregnancy  may  be  very 
difficult  to  diagnose  from  the  latter  condition.  In  this  connection 
it  should  always  be  remembered  that  the  most  frequent  cause  of 
such  hemorrhage  is  undoubtedly  ectopic  gestation. 

It  is  necessary  that  the  case  should  be  studied  with  the  greatest 
care,  because  of  the  risks  to  the  life  of  the  patient  that  follow  the 
rupture  of  ectopic  gestation  sacs. 

8.  Inflammatory  Swellings  in  tlie  Pelvis. — Various  swell- 
ings that  may  be  produced  in  the  pelvis  as  the  result  of  inflamma- 
tion must  be  diagnosed  from  ectopic  pregnancy.  The  risk  of  making 
an  error  is  greater  when  the  uterus  has  been  recently  pregnant 
or  when  the  inflammation  complicates  actual  normal  pregnancy. 

9.  Malignant  swellings  occasionally  cause  error  in  diagnosis. 
In  most  cases  the  error  has  been  due  to  the  formation  of  a  malig- 
nant swelling  resembling  somewhat  the  shape  of  the  fetus  in  its 
gestation  sac.  Sometimes  such  a  condition  may  be  very  perplex- 
ing when  it  is  found  at  the  time  of  the  menopause,  especially  if 
menstrual  irregularities  and  some  of  the  minor  changes  usually 
found  in  pregnancy  be  present. 

10.  Gestation  in  the  Rudimentary  Horn  of  a  Malformed 
Uterus. — Tills  condition  can  be  definitely  diagnosed  from  ectopic 


41 8  ECTOPIC  PREGNANCY. 

pregnancy  only  if  the  shape  of  the  malformed  horn  can  be  accu- 
rately outlined.  This  is  rarely  done,  but  for  practical  purposes 
accuracy  is  not  necessary,  since  both  conditions  demand  the 
same  treatment. 

11.  Gestation  in  a  well=formed  Bicornute  Uterus. — When 
one  half  of  a  bicornute  uterus  is  pregnant,  the  condition  may 
strongly  resemble  an  ectopic  gestation.  In  the  former  case  the 
finger  may  usually  feel  the  fetus  in  advanced  pregnancy  if  the 
cervix  be  patulous. 

12.  Spurious  Pregnancy. — This  condition  may  be  mistaken 
for  ectopic  pregnancy.  The  menses  may  cease  for  several  months 
or  may  be  irregular.  There  may  be  changes  in  the  breasts  and 
various  other  manifestations  of  pregnancy.  When  the  uterus  is 
found  empty  on  bimanual  examination,  it  may  be  thought  that  an 
ectopic  gestation  is  present,  especially  if  there  be  a  swelling  of  any 
kind  in  the  abdomen  or  pelvis.  In  such  cases  an  anesthetic 
examination  should  always  be  made. 

13.  Various  other  conditions  may  simulate  rupture  of  a  gesta- 
tion sac — /'.  r.,  acute  intestinal  obstruction,  perforation  of  the 
intestines,  rupture  of  an  aneur\sm,  renal  and  biliary  colic,  torsion 
of  the  pedicle  of  a  tumor,  etc. 

Treatment. — ia)  When  the  Gestation  is  Confined  to  its 
Original  Site  in  the  Ampullar  or  Infundibular  Portion  of  the 
Tube  or  in  the  Ovary. — As  soon  as  the  diagnosis  is  established 
the  patient  should  be  kept  at  rest,  in  order  to  avoid  any  form  of 
exertion  that  might  bring  about  rupture  of  the  gestation  sac. 
Abdominal  section  should  be  carried  out  and  the  gestation  re- 
moved, the  procedure  being  the  same  as  in  the  case  of  the  removal 
of  a  tube  much  altered  by  disease. 

In  such  conditions  the  chief  difficult}'  arises  when  the  gestation 
sac  is  impacted  in  the  pehis  or  is  extensively  adherent  to  sur- 
rounding structures.  If  the  sac  be  ruptured  during  operation, 
considerable  hemorrhage  ma}-  result.  It  is,  therefore,  always 
advisable  before  removal  to  ligate  the  ovarian  artery  on  the 
affected  side.  When  the  gestation  sac  occupies  a  considerable 
portion  of  the  abdomen  and  is  so  adherent  that  its  removal  is 
impossible  without  dangerous  loss  of  blood,  it  may  be  advisable 
to  carry  out  a  procedure  similar  to  that  described  in  connection 
with  subperitoneo-abdominai  cases. 

(/;)  Interstitial  Tubal  Pregnancy. — Several  cases  have  been 
reported  in  which  the  cerxix  has  been  dilated  and  the  septum 
between  the  uterine  cavity  and  the  gestation  sac  divided  so  as  to 
allow  the  removal  of  the  ovum.  This  procedure  should  be  under- 
taken only  in  the  early  months,  when  there  is  considerable  prob- 
ability that  it  may  be  satisfactorily  accomplished  or  when  there  is 
some  contraindication  to  abdominal  section.  The  chief  risk  is 
that  the  outer  wall  of  the  gestation  sac  may  be  ruptured,  leading 


TREA  TMENT.  4 1 9 

to  extra-uterine  hemorrhage.  This  is  most  Hkely  to  occur  in 
separating  the  placenta  manually.  After  removal  of  the  preg- 
nant mass  the  cavity  should  be  packed  with  gauze  for  several 
days. 

In  a  great  majority  of  these  cases,  however,  abdominal  section 
is  the  safest  procedure  ;  if  the  gestation  be  not  too  far  advanced,  it 
may  be  possible  to  remove  the  pregnant  portion  of  the  uterus, 
closing  the  cavity  as  after  a  myomectomy.  When  the  gestation 
is  advanced,  however,  it  is  advisable  to  remove  the  whole  uterus, 
as  in  the  operation  of  hysterectomy  for  a  large  fibroid. 

{c)  When  the  Gestation  Sac  has  Ruptured  into  the  Peritoneal 
Cavity. — When  rupture  is  accompanied  with  acute  symptoms  of 
loss  of  blood,  abdominal  section  is  indicated.  All  precautions 
should  be  taken  to  counteract  the  influence  of  the  blood-loss 
before  and  during  the  operative  procedure, — i.  e.,  the  introduction 
of  normal  saline  solution  into  the  system, — and  the  latter  should  be 
quickly  carried  out.  In  opening  the  abdomen  it  is  imperative  first 
of  all  to  find  the  place  of  rupture,  in  order  that  the  bleeding 
vessels  may  be  controlled.  Also  the  ovarian  vessels  on  the  side 
of  the  gestation  should  be  early  clamped  or  ligated.  If  the  tear 
be  large  or  irregular,  it  may  be  impossible  to  do  this  quickly,  or 
attempts  at  compression  may  increase  the  size  of  the  tear.  In  such 
cases  the  assistants  should  compress  both  broad  ligaments  while 
the  operator  carries  out  his  manipulations. 

The  gestation  sac  should  be  removed  as  would  be  an  inflam- 
matory swelling,  and  complications  should  be  treated  in  the  ordi- 
nary manner. 

In  cases  of  rupture  in  which  dangerous  loss  of  blood  has  not 
at  once  occurred,  but  a  succession  of  small  hemorrhages,  abdomi- 
nal section  is  also  advisable.  Cases  seen  after  hemorrhage  has 
ceased  may  be  treated  expectantly,  in  order  that  the  hematocele 
may  have  a  chance  to  absorb.  If  this  does  not  take  place  with 
reasonable  rapidity,  operation  should  be  carried  out,  the  blood- 
clots  removed,  and  the  gestation  sac  taken  away,  if  possible. 
Abdominal  or  vaginal  drainage  may  be  necessary  afterward. 

The  gestation  sac  being  removed,  the  operation  is  very  likely 
to  be  complicated  in  such  conditions  by  the  presence  of  numerous 
adhesions  and  by  blood-clots  in  all  stages  of  formation.  The 
most  careful  technic  must  be  observed,  the  clots  being  carefully 
removed,  and  the  abdominal  cavity  being  flushed  out  with  normal 
saline  solution. 

In  the  rare  cases  in  which  after  the  rupture  of  the  primary 
sac  the  fetus  escapes  in  its  membranes  and  continues  to  grow 
in  the  peritoneal  cavity,  abdominal  section  should  also  be  carried 
out.  The  secondary  sac  should  be  opened  first  of  all,  the  fetus 
and  amniotic  fluid  being  removed.  Thereafter,  if  the  primary  sac 
is  movable  and  the  adhesions  surrounding  it  are  easily  divided,  the 


420  ECTOPIC  PREGNANCY. 

mass  containing  the  placenta  should  be  taken  away.  As  much 
of  the  amnion  as  is  loosely  attached  may  be  stripped  away.  It 
should  not  be  forcibly  torn  off,  however,  because  of  the  danger  of 
injuring  the  viscera.  When  the  primary  sac  is  too  firmly  em- 
bedded in  the  pelvis  or  in  adhesions  to  allow  of  its  safe  removal, 
the  ovarian  artery  of  the  affected  side  should,  at  least,  be  ligated. 
The  umbilical  cord  should  be  brought  to  the  lower  end  of  the 
abdominal  incision  and  a  gauze  tampon  inserted  from  the  latter 
down  to  the  placenta. 

After  four  or  five  days  the  patient  should  be  anesthetized,  the 
packing  removed,  and  an  effort  made  to  detach  the  placenta. 
Sometimes  onh'  a  portion  of  it  may  be  taken  away  at  this  time. 
The  cavity  should  be  again  packed,  and  the  rest  of  the  placenta 
be  removed  several  days  later.  The  cavity  is  afterward  allowed 
to  close  gradually. 

id)  When  the  Primary  Gestation  Ruptures  into  the  Broad 
Ligament. — At  the  time  of  primar}'  rupture  the  patient  should 
be  placed  at  rest  in  bed,  a  simple  light  diet  being  administered, 
and  an  ice-coil  or  ice-bag  should  be  placed  over  the  lower  abdomi- 
nal region,  ergot  being  administered  internally.  The  pelvis  should 
be  examined  from  time  to  time,  in  order  to  determine  if  the  mass 
tends  to  increase  in  size.  If  the  ovum  be  destroyed,  no  further 
treatment  may  be  necessar\-,  in  some  cases  the  swelling  in  the 
broad  ligament  gradually  disappearing.  If  the  disappearance 
takes  place  veiy  slowl}'  or  pressure  symptoms  are  present,  it  is 
wise  to  make  a  vaginal  incision  into  the  mass,  remove  blood-clots, 
and  pack  the  cavity  with  antiseptic  gauze. 

In  cases  in  which  after  rupture  the  ovum  continues  to  develop, 
so  that  the  swelling  reaches  upward  into  the  abdomen,  it  is  some- 
times possible  to  carr}'  out  \aginal  operation.  This  should  be 
done  when  the  amniotic  cavity  is  felt  to  bulge  downward  behind 
the  uterus,  the  placenta  being  above  the  level  of  the  fornix.  By 
incising  the  gestation  sac  the  liquor  amnii  and  fetus  may  be  re- 
moved. An  antiseptic  gauze  tampon  may  then  be  inserted  into 
the  sac,  which  gradually  shrinks.  After  four  or  five  days  the 
gauze  may  be  removed  and  an  effort  made  to  take  awa}-  part  or 
all  of  the  placenta.  The  cavity  should  be  again  packed,  and 
should  afterward  be  treated  as  a  pelvic  abscess  cavity. 

When  the  placenta  is  situated  low  in  the  pelvis  or  the  gesta- 
tion sac  has  adv-anced  several  inches  above  the  brim  of  the  pelvis, 
the  abdominal  route  should  be  selected  and  a  mesial  or  lateral 
incision  made,  the  sac  opened,  the  fetus  and  liquor  amnii  ex- 
tracted, and  the  cavity  packed  with  antiseptic  gauze,  the  umbilical 
cord  being  carried  into  the  abdominal  wound.  The  edges  of  the 
gestation  sac  should  be  stitched  to  the  edges  of  the  abdominal  in- 
cision. This  method  of  treatment  may  be  greatly  complicated  if 
the  abdominal  incision  is  made  through  the  placental  area,  as  the 


TREA  TMENT.  42 1 

loss  of  blood  may  be  very  rapid.  To  lessen  this  risk  the  cavity 
should  be  packed  with  the  greatest  rapidity. 

Alter  four  or  five  days  the  gauze  should  be  removed  and  the 
placenta  entirely  or  partially  taken  away.  No  force  should  be 
employed  in  this  procedure.  Thereafter  the  cavity  may  be  packed 
every  few  days  until  it  gradually  shrinks  and  closes.  Removal 
of  the  placenta  at  the  time  of  primary  operation  is  not  advisable 
on  account  of  the  danger  of  hemorrhage.  In  cases  in  which  in- 
fection of  the  cavity  may  follow  this  procedure  the  healing-process 
is  delayed.  It  may  be  greatly  hastened  if  a  vaginal  incision  can 
be  safely  made  into  the  sac,  so  that  downward  drainage  may  be 
carried  out. 

{e)  When,  after  Rupture  of  the  Primary  Gestation  Sac  into 
the  Broad  Ligament,  Rupture  takes  place  into  the  Peritoneal 
Cavity. — When  secondary  rupture  occurs  soon  after  the  primary 
rupture,  abdominal  section  must  be  carried  out  and  the  case 
treated  on  the  lines  laid  down  for  the  management  of  primary 
rupture  of  the  gestation  sac  into  the  peritoneal  cavity.  When  the 
rupture  occurs  after  the  ovum  has  been  developing  extraperi- 
toneally  for  some  time,  the  abdominal  cavity  should  be  opened, 
the  vessels  in  the  edges  of  the  tear  closed,  and  the  latter  stitched 
to  the  edge  of  the  abdominal  incision  if  near  enough. 

If  the  rent  be  too  far  from  the  abdominal  wall,  it  should  be  closed 
with  catgut,  the  peritoneal  cavity  flushed  out  with  normal  saline 
solution,  and  the  sac  opened  anteriorly,  being  treated  in  the  manner 
already  described. 

(/^)  When  the  Case  has  Reached  the  Advanced  Months 
of  Pregnancy. — Abdominal  section  is  always  indicated.  There 
should  be  no  delay  unless  at  the  express  desire  of  the  parents,  in 
order  to  take  chances  of  securing  a  more  developed  fetus.  Such 
a  course  is,  however,  unwise  ;  waiting  adds  to  the  risks  and  dis- 
comforts of  the  mother.  As  regards  the  fetus  there  is  great 
uncertainty. 

In  the  case  of  ectopic  pregnancy  the  fetus  is  less  robust  than 
in  the  case  of  uterine  pregnancy,  and  there  is  great  liability  to 
death  at  or  near  full  term.  When  the  operation  is  carried  out 
after  there  has  been  a  spurious  labor,  followed  by  death  of  the 
child,  the  risks  of  hemorrhage  are  much  reduced  and  the  chance 
of  removing  the  placenta  considerable. 

When  the  fetus  has  been  long  dead  and  it  has  been  mummified, 
transformed  into  adipocere  or  alithopedion,  removal  by  abdominal 
section  is  always  indicated.  The  fetus  should  be  taken  out,  and 
its  membranes  or  sac  with  it,  if  they  be  easily  detachable. 

{(t)  When  Suppuration  has  taken  place  in  an  Old  or  Recent 
Gestation. — In  these  conditions  the  procedure  usually  adopted 
for  pelvic  or  abdominal  abscesses  should  be  employed.  The 
vaginal   incision   should   always   be   chosen   if  possible.      If  the 


422  ECTOPIC  PREGNANCY. 

abdominal  route  be  selected,  care  should  be  taken  not  to  infect 
the  peritoneal  cavity.  In  cases  of  spontaneous  rupture  of  the 
infected  sac  there  may  be  great  delay  in  the  healing  if  the  fetus 
has  been  so  far  advanced  that  its  skeleton  has  been  well  formed. 
Its  bones  pass  out  very  slowly  and  may  greatly  impede  the 
escape  of  pus.  It  may  be  necessary  to  remove  the  contents  by 
hands  or  instruments,  and  an  incision  may  be  required. 

(/{)  When  there  is  a  Combination  of  Ectopic  and  Normal 
Uterine  Pregnancy. — When  the  gestation  is  of  old  standing,  as 
in  the  case  of  a  lithopedion,  a  uterine  gestation  rhay  sometimes 
progress  normally  and  be  delivered  satisfactorily.  Sometimes 
premature  emptying  of  the  uterus  may  result  from  the  interference 
caused  by  the  old  gestation  mass.  In  other  cases  full  time  may 
be  reached,  but  labor  may  be  obstructed  and  artificial  delivery 
may  be  necessary.  When  an  ectopic  gestation  is  in  the  condition 
of  active  growth,  the  complication  is  very  serious.  Rarely  a 
uterine  pregnancy  may  go  to  full  term  and  delivery  occur  without 
rupture  of  the  ectopic  sac ;  the  latter  occurrence  is,  however, 
likely  to  occur.  Usually  in  such  a  condition  it  is  advisable  to 
carry  out  abdominal  section,  removing  the  ectopic  gestation  and 
allowing  the  uterine  pregnancy  to  continue.  Sometimes  it  may 
be  necessary  to  terminate  the  latter  also,  though  such  a  procedure 
greatly  increases  the  risk  to  the  mother. 

(/)  Rudimentary=horn  Gestation. — This  condition  is  a  grave 
one,  and  is  to  be  treated  according  to  the  rules  laid  down  for  the 
management  of  tubal  pregnancy. 


PART   V. 

THE  PATHOLOGY  OF  LABOR. 


In  considering  the  different  complications  of  labor  which  make 
that  process  difficult  or  dangerous  it  is  convenient  to  consider 
them  in  three  groups  :  i.  Those  relating  to  the  powers.  2.  Those 
relating  to  the  passages.     3.  Those  relating  to  the  passenger. 


CHAPTER    I. 

ANOMALIES  OF  THE  EXPELLANT  POWERS, 

(a)  Bxcess  ;  Precipitate  I/abor. — Excessive  Uterine  Con= 
tractions. — Excessive  activity  of  the  uterus  may  be  manifested 
by  increased  frequency,  intensity,  or  duration  of  the  pains.  In 
some  cases  all  these  features  may  be  combined.  Sometimes 
they  may  be  present  from  the  beginning  of  labor;  sometimes 
they  may  develop  in  the  course  of  the  first  or  second  stage. 
When  intense  pains  succeed  one  another  rapidly,  the  patient  be- 
comes distressed  and  restless  and  the  pulse-rate  rises.  Frequently 
in  the  first  stage  she  may  make  involuntary  straining-efforts. 
Sometimes  these  are  so  violent  as  to  cause  fracture  of  the  ribs, 
emphysema  of  the  throat  and  chest,  and  hemorrhages  in  the 
trachea  and  bronchi. 

If  there  be  obstruction  to  the  passage  of  the  fetus,  the  results 
may  be  very  serious,  both  to  the  mother  and  child.  When  there 
is  no  obstruction,  delivery  may  be  very  rapid.  Frequently  after 
rupture  of  the  membranes  the  fetus  may  be  expelled  in  a  few 
seconds  or  minutes. 

Precipitate  labor  is  most  apt  to  occur  in  multiparae,  especially 
in  biparae,  though  in  a  considerable  number  of  cases  it  is  noted  in 
primiparae.  It  is  favored  by  a  small  fetus,  large  pelvis,  and  by  an 
inclination  of  the  pelvis  that  establishes  the  most  direct  continuity 
between  the  axis  of  the  uterus  and  that  of  the  upper  part  of  the 
pelvic  cavity.  Bayer  has  collected  808  cases ;  in  these  the  labor 
occurred   in    273   standing,  in  Cyy  walking,  and   in   234  sitting  or 

428 


424  ANOMALIES   OF   THE   EXPELLANT  POWERS. 

squatting.  Previous  precipitate  labors  exercise  a  predisposing 
influence. 

In  some  cases  excessive  action  of  the  voluntary'  muscles  may 
be  an  important  factor  in  hastening  the  delivery.  Sometimes 
sudden  births  are  those  in  which  the  head  has  reached  the  pelvic 
floor  by  a  painless  descent,  the  expulsion  occurring  thereafter  by 
a  few  strong  contractions. 

Precipitate  labors  are  frequently  associated  with  complications 
— /.  e.,  laceration  of  the  soft  parts,  hemorrhage,  separation  of  the 
placenta,  inversion  of  the  uterus,  and  rupture  of  the  cord. 
Winckel  states  that  lacerations  are  three  times  as  frequent  as  in 
normal  labors  in  multiparae.  The  risks  are  greater  when  the 
woman  happens  to  be  sitting  or  standing  ;  the  labor  is  likely  to 
be  more  precipitate  than  it  is  when  the  woman  is  lying  down. 
The  fetus  may  be  injured  when  it  is  forcibly  expelled  ;  fractures 
may  be  caused,  or  the  fetus  may  so  fall  on  its  face  as  to  be  pre- 
vented from  breathing.  Sometimes,  when  the  woman  is  unat- 
tended, the  infant  may  die  before  it  is  cared  for.  After  these 
labors  there  are  apt  to  be  uterine  inertia  and  postpartum  hemor- 
rhage ;  there  is  also  greater  risk  of  infection  than  in  normal  cases, 
chiefly  on  account  of  the  lacerations. 

Asphyxiation  of  the  fetus  follows  excessive  compression  of  the 
placenta ;  intracranial  hemorrhage  or  fracture  of  the  skull  may 
sometimes  be  produced  by  violent  uterine  contractions. 

Treatment. — When  there  is  a  history  of  a  previous  precipitate 
labor,  the  woman  should  be  advised  not  to  go  far  from  her  house 
during  the  last  week  or  two  of  her  pregnancy  and  to  avoid  strain- 
ing at  stool.  When  excessive  activity  of  the  uterus  is  noted  in 
labor,  the  woman  should  be  placed  in  bed  and  not  allowed  to  walk 
about,  especially  if  there  is  a  histor}'  of  a  former  precipitate  labor. 
She  should  be  urged  not  to  strain  during  the  pains  in  the  first 
stage.  To  moderate  their  intensity,  chloral  may  be  given  or  a 
little  chloroform  may  be  inhaled  at  the  beginning  of  a  pain. 
Morphin  should  be  used  only  when  absolutely  necessary,  on 
account  of  the  risk  of  affecting  the  fetus.  When  dilatation  of  the 
cervix  causes  intense  suffering,  it  is  recommended  by  some  to 
apply  cocain  solution  (4  to  10  per  cent.)  to  the  cervix.  In  the 
second  stage  the  perineum  must  be  carefully  guarded  and  the  head 
not  allowed  to  pass  too  quickly.  In  the  third  stage  the  body  of 
the  uterus  must  be  controlled  by  a  hand  placed  on  the  abdomen. 
Precautions  must  be  taken  to  prevent  postpartum  hemorrhage. 

(/?)  Delayed  I^abor;  Inertia  Uteri. — Defective  Uterine 
Contractions. — Labor  may  be  delayed  from  weak,  short,  or  infre- 
quent uterine  contractions.  Weakness  must  be  regarded  as  rela- 
tive, for  pains  that  might  be  sufficient  to  bring  about  delivery  in 
some  cases,  migrht  be  ineffectual  if  there  be  increased  resistance. 
In  some  cases  the  pains  may  cease  entirely. 


DELAYED   LABOR;    INERTIA    UTERI.  425 

Etiology. — The  following  causes  may  be  enumerated  :  Debilitated 
constitution,  exhausting  disease ;  uterus  weakened  because  of 
congenital  malformation,  inflammation,  or  too  frequent  child- 
bearing  ;  adhesions  to  neighboring  structures ;  tumors  of  the 
uterus  or  of  neighboring  tissues  ;  distention  of  the  bladder  or 
intestine  ;  displacement  of  the  uterus  ;  premature  escape  of  the 
liquor  amnii ;  pregnancy  in  an  old  primipara ;  hydramnios  ;  twin 
pregnancy ;  fright  or  mental  emotion.  Usually  in  the  early  stage 
of  labor  in  cases  of  placenta  previa  there  is  some  uterine  inertia. 
Strong  pains  may  be  succeeded  by  weak  contractions  in  cases  of 
obstructed  labor  due  to  various  causes — /.  c,  strong  and  adherent 
membranes,  contracted  hard  or  soft  parts,  large  fetus,  malpresen- 
tations,  malpositions,  etc. 

Symptoms. — In  the  first  stage  the  membranes  do  not  get  very 
tense  or  bulge  down  during  contractions  and  may  be  easily  pushed 
up.  The  cervix  dilates  slowly  or  not  at  all.  If  the  membranes 
are  ruptured,  the  fetus  makes  little  or  no  advance.  In  cases  of 
long  delay — /.  e.,  more  than  twenty -four  hours^the  woman  usually 
shows  evidence  of  fatigue.  She  may  be  anxious  and  restless,  the 
skin  gets  dry,  the  pulse  rapid  and  small  in  volume,  and  the  tem- 
perature elevated.  In  extreme  cases  the  patient  becomes  much 
reduced,  the  tongue  furred  and  dry,  nausea  and  vomiting  super- 
vene, the  face  becomes  swollen,  and  delirium  and  coma  may  follow. 
The  vagina  and  vulva  frequently  become  dry,  congested,  edema- 
tous, and  tender,  and  there  may  be  pains  in  the  pelvis,  abdomen, 
and  thighs.  Death  may  result  if  the  woman  is  not  delivered  early 
enough.  The  life  of  the  fetus  is  endangered  ;  its  movements  may 
become  violent,  its  heart-beat  increasing  and  then  becoming 
slowed,  and  it  may  finally  die  from  asphyxiation,  especially  when 
the  membranes  have  been  ruptured.  During  the  third  stage  in 
such  cases  there  may  be  inertia,  retention  of  the  placenta,  and 
hemorrhage.  Afterward  there  may  be  uterine  relaxation,  hemor- 
rhage, and  accumulation  of  clots  in  utcro. 

Prognosis. — The  risk  to  the  fetus  is  very  great  if  the  membranes 
have  ruptured  prematurely.  Great  variations  are,  however,  found, 
and  it  is  impossible  to  state  an  exact  Hmit  beyond  which  death  of 
the  fetus  takes  place.  Change  in  rhythm  of  the  fetal  heart  is  a 
danger  sign  ;  also  passage  of  meconium  in  a  breech  presentation. 
Increase  in  pulse,  temperature,  and  respiration  in  the  mother  and 
swelling  of  the  soft  passage  indicate  a  serious  condition.  The 
longer  the  delay,  the  worse  is  the  prognosis. 

Treatment. — Remedial  measures  vary  according  to  the  cause 
of  weak  contractions,  their  extent,  and  the  stage  of  labor.  The 
mere  fact  that  labor  is  prolonged  does  not  always  imply  the  ne- 
cessity of  terminating  it.  The  condition  of  the  mother  and  fetus 
determines  the  indication.  If  there  be  general  weakness,  stimu- 
lants may  be  necessary.     If  the  bladder  or  bowel  be  distended,  it 


426  ANOMALIES   OF  THE   EXPELLANT  POWERS. 

should  be  emptied.  In  the  first  stage,  if  the  patient  be  tired,  if 
the  membranes  are  intact,  it  is  advisable  to  administer  opium, 
morphin,  or  chloral,  or  a  combination  of  morphin  and  chloral,  in 
order  that  the  patient  may  have  a  rest  and  a  sleep ;  at  the  same 
time  some  light  food  may  be  given.  Often  after  such  a  spell  she 
may  awake  refreshed  and  go  through  her  labor  satisfactorily.  If 
the  patient  be  not  exhausted,  quinin  should  be  administered  (the 
hydrobromate  is  least  apt  to  disturb  the  system),  in  order  to 
strengthen  the  pains.  Fifteen  grains  may  be  given  within  thirty 
minutes.  In  large  doses  this  drug  does  not  tend  to  cause  tetanic 
contraction  of  the  uterus.  Massage  of  the  uterus  should  be  carried 
out  through  the  abdominal  wall. 

If  hydramnios  is  present,  it  is  advisable  to  withdraw  the  liquor 
amnii  slowly.  Hot  vaginal  douches  (105°  to  1 10°  F.)  given  every 
hour  are  sometimes  helpful.  A  rubber  bag  distended  in  the  vagina 
may  often  stimulate  the  uterus.  In  cases  in  which  the  membranes 
are  ruptured,  a  Champetier  de  Ribes  bag  placed  in  the  lower  part 
of  the  uterus  and  distended  may  cause  labor  to  proceed  satis- 
factorily. When  the  weak  pains  occur  in  the  second  stage,  quinin 
may  be  administered  and  the  uterine  body  massaged.  The  method 
of  expression  recommended  by  Kristeller  in  1867  may  be  tried. 
The  fundus  should  be  grasped  anteroposteriorly  between  the 
fingers  and  thumbs  of  the  hands  placed  side  by  side  on  the  ab- 
dominal wall,  care  being  taken  not  to  include  the  intestine  in 
the  grasp,  if  possible.  Downward  pressure  is  made  in  the  axis 
of  the  pelvic  inlet,  at  first  gradually,  then  with  more  force,  ten 
or  fifteen  seconds,  then  gradually  relaxing.  This  manipula- 
tion is  repeated  at  intervals  of  one  to  five  minutes,  preferably 
during  pains.  When  the  patient  is  ver}'  sensitive,  an  anesthetic 
may  be  given.  If  the  uterus  lies  laterally,  it  should  be  moved  so 
as  to  He  mesially.  Kristeller's  manipulations  may  succeed  in 
bringing  about  descent  of  the  fetus  as  well  as  stimulating  the 
uterus.  Hofmeier  recommends  that  the  head  alone  be  pressed 
down,  the  hands  of  the  obstetrician  being  placed  on  the  abdomen, 
above  the  brim,  one  over  the  occiput,  the  other  over  the  face.  It 
may  also  be  necessary  to  apply  forceps  in  head  presentations,  or 
to  carry  out  manual  traction  along  with  pressure  from  above  if 
the  breech  presents.  These  measures  may  be  adopted  if  the 
second  stage  has  lasted  three  and  a  half  hours  in  primiparae  or 
two  and  a  half  hours  in  multiparas. 

Irregular  Uterine  Contractions. — The  uterine  contractions 
may  be  irregular  as  regards  their  occurrence  or  as  regards  the 
amount  of  uterine  wall  involved.  They  may  be  very  painful  but 
ineffective.  The  pain  is  usually  localized  when  part  of  the  uterus 
only  is  active.  In  some  cases  the  activity  may  be  localized  to  the 
region  of  the  retraction  ring.  In  some  cases  a  tetanic  condition 
of  the  uterine  body  is  produced.     The  causes  of  these  irregularities 


ANOMALIES   OF   THE   ACCESSORY  MUSCLES.  427 

are  not  definitely  known.  They  are  sometimes  present  in  pro- 
longed or  difficult  labors,  especially  when  there  is  some  definite 
obstruction ;  sometimes  after  premature  rupture  of  the  mem- 
branes. They  are  apt  to  follow  the  administration  of  ergot  during 
labor,  especially  the  tetanic  variety. 

In  examining  the  uterus  during  partial  contraction,  one  portion 
of  the  wall  may  be  felt  to  harden  while  another  remains  uncon- 
tracted.  No  bulging  of  the  membranes  or  dilatation  of  the  cervix 
may  be  present  during  the  pain.  When  the  retraction  ring  is 
affected,  it  may  be  felt  hard  and  firmly  pressed  against  the  fetus. 
In  the  tetanic  condition  the  whole  uterus  remains  firm  and  is 
moulded  on  the  fetus  if  the  liquor  amnii  has  escaped. 

Prognosis. — In  irregular  contractions  the  labor  is  delayed  and 
the  woman  becomes  restless  and  wearied.  The  tetanic  condition 
may  lead  to  uterine  rupture,  may  cause  fracture  of  the  head  of 
the  fetus,  and  is  apt  to  cause  its  asphyxiation  by  compression  of 
the  placenta  or  cord. 

Treatment. — In  mild  cases  chloral  or  morphin  may  be  given  ; 
hot  vaginal  douches  may  be  helpful.  In  severe  cases  chloroform 
may  be  necessary.  Sometimes  artificial  delivery  is  advisable,  the 
cervix  being  dilated  if  necessary.  In  the  tetanic  condition  it  may 
sometimes  be  impossible  to  remove  the  fetus  except  by  embry- 
otomy. In  some  cases  Caesarean  section  may  be  advisable.  In 
the  third  stage  there  may  be  difficulty  in  connection  with  the  de- 
livery of  the  placenta. 

Anomalies  of  the  Accessory  Muscles. — Ordinarily  the 
accessory  muscles  become  active  after  the  first  stage,  the  patient 
straining  during  the  uterine  contractions.  Occasionally  they  may 
act  during  the  first  stage,  especially  when  the  uterine  pains  are 
intense.  Sometimes  the  woman  may  inhibit  them  from  fear.  In 
heart  and  lung  conditions  associated  with  dyspnea  it  may  be  im- 
possible to  use  them.  In  general  debility  or  emaciation  the  muscles 
may  be  weak.  Their  action  may  be  largely  ineffectual  when  there 
has  been  marked  separation  of  the  recti  abdominis,  especially  when 
there  has  been  a  pendulous  belly  during  pregnancy.  Excessive 
obesity  is  said  to  weaken  them.  In  lesions  of  the  spinal  cord  they 
may  be  inactive.  When  the  lower  limbs  are  diseased  or  amputated, 
they  cannot  act  as  effectively  as  in  normal  cases,  because  the 
pelvis  cannot  be  fixed  during  straining.  Distended  intestines, 
ascites,  and  abdominal  tumors  interfere  with  the  efficiency.  As  a 
rule,  weakness,  absence,  or  inefficiency  of  contractions  of  the  ac- 
cessory muscles  delays  labor.  Sometimes,  however,  this  is  not 
the  case,  the  uterus  being  able  to  expel  the  fetus. 

The  treatment,  as  a  rule,  consists  in  artificial  delivery  if  labor 
tends  to  be  unduly  delayed.  Kristeller's  manipulation  may  be 
tried  during  the  second  stage.  When  the  linea  alba  is  much 
stretched,  an  abdominal  binder  may  be  of  some  assistance. 


428  ANOMALIES   OF   THE   PASSAGES. 

CHAPTER    II. 

ANOMALIES  OF  THE  PASSAGES. 
SOFT  PARTS. 

Malformations  of  the  Uterus. — Labor  may  take  place 
satisfactorily  when  a  unicornute  uterus  is  pregnant.  Owing  to 
the  inclination  of  the  long  uterine  axis  to  the  pelvic  brim  there 
may  be  malpresentations  and  malpositions,  though  these  are  not 
as  frequent  as  might  be  expected,  since  the  enlarged  uterus  at  the 
end  of  pregnancy  tends  to  lie  more  symmetrical!}'  in  the  abdomen 
than  in  the  non-pregnant  state.  When  one  horn  of  a  bicornute 
uterus  is  pregnant,  the  condition  is  much  the  same  as  in  the  pre- 
ceding case.  Obstruction  to  the  passage  of  the  fetus  may  some- 
times be  caused  by  the  non-pregnant  horn.  Rarely  both  horns 
are  pregnant,  and  when  labor  occurs,  each  may  obstruct  the  other. 
(Pregnancy  in  a  rudimentary  horn  is  considered  in  connection  with 
Ectopic  Gestation.)  When  one  half  of  a  septate  uterus  is  pregnant, 
labor  may  be  obstructed  by  the  septum  or  by  the  empty  part  of 
the  uterus. 

In  all  these  conditions  labor  may  be  prolonged  and  the  uterine 
contractions  weak,  irregular,  inefficient,  and  sometimes  very  pain- 
ful. Rupture  of  the  uterus  ma)'  take  place.  The  placenta  may 
be  retained  and  there  may  be  postpartum  hemorrhage. 

Treatment. — In  some  cases  the  management  is  the  same  as 
under  normal  conditions  ;  sometimes  forceps  may  be  necessary. 
Version  should  be  employed  as  little  as  possible,  owing  to  the 
risk  of  rupturing  the  uterus  in  such  cases.  When  a  septum  is  an 
obstruction,  it  should  be  divided,  if  possible.  Embryulcia  or 
Caesarean  section  is  sometimes  required. 

Malpositions  of  the  Uterus. — Obliquity  of  the  Uterus. — 
The  long  axis  of  the  uterus  may  be  inclined  so  much  to  one  or 
the  other  side  or  to  the  front  as  to  cause  trouble  in  labor.  When 
the  fundus  is  displaced  anteriorly,  the  condition  is  often  termed 
anteversion,  being  due  to  weakness  of  the  anterior  abdominal 
wall,  resulting  from  separation  of  the  recti  abdominis  muscles. 
Marked  tilting  to  one  side  may  be  due  to  adhesions  or  the  presence 
of  a  tumor.  When  these  obliquities  are  present  during  labor,  much 
of  the  force  of  uterine  contractions  is  inefficient  because  the  long 
axis  of  the  uterus  is  not  in  line  with  the  axis  of  the  inlet.  More- 
over, malpresentations  and  malpositions  are  apt  to  be  produced. 

Treatment. — The  obliquity  should  be  corrected  as  much  as 
possible  and  a  binder  applied  to  the  abdomen,  the  patient  being 
kept  in  bed  on  her  back  as  much  as  possible.  Version  may  some- 
times be  necessary  on  account  of  a  malpresentation  or  malposition 
that  may  be  caused  by  the  obliquity. 


MALPOSITIONS    OF   THE    UTERUS.  429 

Hernia. — Rarely  the  pregnant  uterus  may  form  part  or  the 
whole  of  an  umbilical,  ventral,  inguinal,  or  femoral  hernia.  The 
uterus  may  be  normal,  unicornute,  or  part  of  a  bicornute  organ. 
The  hernia  may  be  congenital  or  may  develop  before  or  during 
pregnancy.  The  uterus  may  sometimes  be  drawn  into  the  sac  by 
adhesions  to  intestines  or  may  be  secondary  to  an  ovarian  hernia. 

Treatment. — Reduction  of  the  hernia  should  be  attempted. 
If  this  be  impossible,  the  uterus  should  be  opened  and  emptied, 
hysterectomy  being  carried  out  if  a  conservative  operation  cannot 
be  safely  performed. 

Prolapsus  Uteri. — Partial  prolapse  of  the  pregnant  uterus  is 
occasionally  found,  but  it  is  extremely  rare  that  any  considerable 
portion  of  the  uterus  lies  outside  of  the  vulva  at  full  term.  In 
the  minor  degrees  the  lower  part  of  the  uterus  may  be  elevated 
after  uterine  contractions  have  been  active  for  a  time.  Sometimes 
this  does  not  take  place,  especially  if  the  cervix  be  rigid  or  hyper- 
trophied,  and  it  may  become  edematous  and  obstruct  the  passage 
of  the  head. 

Treatment. — When  the  cervix  does  not  dilate  readily,  it  may  be 
necessary  to  employ  artificial  means.  Vaginal  Caesarean  section 
is  advisable  if  dilatation  is  impossible  without  excessive  tearing. 
When  the  cervix  tends  to  be  pushed  down  before  the  head,  arti- 
ficial dilatation  should  be  carried  out,  and  its  descent  should  be 
prevented  as  much  as  possible  by  the  hands.  When  labor  is 
tedious,  it  is  advisable  to  apply  forceps  if  the  cervix  be  sufficiently 
dilated. 

Sacculation. — This  term  is  applied  to  the  condition  in  which 
the  uterine  wall  does  not  distend  uniformly  during  pregnancy,  but 
in  which  one  wall  enlarges  to  a  much  greater  extent  than  the 
other.  Either  the  anterior  or  the  posterior  wall  may  be  affected. 
In  retroversion  of  the  gravid  uterus  the  lower  portion  of  the  pos- 
terior wall  may  develop  and  form  a  diverticulum  behind  the  cervix, 
bulging  the  posterior  vaginal  wall  downward  and  forward,  the 
cervix  itself  being  elevated.  This  sometimes  occurs  in  placenta 
praevia.  It  may  also  take  place  when  tumors  of  the  uterus  or 
neighboring  parts  interfere  with  the  normal  upward  development 
of  the  pregnant  uterus.  It  may  be  found  when  the  organ  is  held 
by  adhesions,  and  when  it  is  prevented  from  rising  by  a  markedly 
contracted  brim.  Sacculation  of  the  posterior  wall  may  also  take 
place  when  pregnancy  occurs  in  a  uterus  that  has  been  rendered 
immobile  in  an  anteverted  position  by  vaginal  fixation  or  ventro- 
fixation. The  anterior  wall  remains  as  a  thick,  unexpanded  mass 
above  the  bladder,  while  the  thin,  expanded  posterior  wall  rises  in 
the  abdomen,  containing  the  fetus.  Sacculation  of  the  anterior 
wall  is  rare,  and  may  extend  upward  when  the  uterus  is  retro- 
verted  and  fixed  by  adhesions.  Downward  sacculation  of  the 
anterior  wall  may  also  occur  when  the  uterus  is  anteverted,  the 


430  ANOMALIES   OF   THE   PASSAGES. 

cervix  being  much  displaced  backward.  In  these  cases,  as  the 
cervix  is  generally  displaced  upward,  normal  labor  isusually  im- 
possible, artificial  delivery  being  necessary.  Abdominal  Csesarean 
section  is  probably  the  most  satisfactory'  treatment,  though  some- 
times vaginal  incision  of  the  sacculated  wall  might  be  employed 
for  removal  of  the  uterine  contents. 

Labor  after  Hysteropexy. — The  various  disturbances  that 
may  follow  operations  that  have  been  carried  out  in  the  treatment 
of  uterine  displacements  have  previously  been  described.  I  have 
already  described  the  serious  complications  that  are  apt  to  follow 
vaginal  fixation  and  ventrofixation,  procedures  that  greatly  limit 
the  normal  movements  of  the  uterus  (p.  337).  In  cases  that  reach 
full  term  there  may  be  malpresentations  and  malpositions,  uterine 
inertia,  non-engagement  of  the  presenting  part,  deviation  of  the 
cervix  backward  or  upward,  delayed  labor,  and  rupture  of  the 
uterus.  Interference  is  necessary  in  these  complications — i.  r., 
dilatation  of  the  cervix,  forceps,  version,  embr^-ulcia,  and  Caesarean 
section. 

Pregnancy  and  I^abor  in  Old  Primiparae. — First  preg- 
nancies in  women  over  thirty  }'ears  of  age  are  more  frequently 
abnormal  than  those  occurring  in  the  preceding  decade.  Abor- 
tion, renal  disorder,  and  eclampsia  are  relatively  frequent.  De 
Koninck  states  that  in  such  women  who  have  been  married 
se\'eral  years  the  first  gestation  is  frequently  twin  or  ectopic. 
Labor  is  ver}^  apt  to  be  delayed,  often  continuing  for  forty  or  fifty 
hours,  and  sometimes  longer,  uterine  contractions  being  usually 
feeble.  Mental  and  physical  exhaustion  is  very  common.  Delay 
also  frequently  occurs  when  the  head  reaches  the  perineum. 
Artificial  deliveiy  is  frequently  necessary.  It  is  held  by  some 
that  the  percentage  of  male  children  is  relatively  large  in  the  first 
labors  of  old  primiparae. 

Pregnancy  and  I^abor  in  Young  Primiparae. — Spitta 
has  reviewed  the  histories  of  260  labors  in  primiparae  of  eighteen 
and  under,  as  observed  in  the  Marburg  Maternity.  He  states 
that  the  general  health  is  not  worse  than  the  average  among  other 
pregnant  women.  Labor  before  the  fortieth  week  was  relatively 
frequent.  Labor  is  often  prolonged  and  the  pains  weak.  Flooding 
is  common,  as  are  lacerations  of  the  soft  parts.  Artificial  delivery 
is  often  necessar}-'.  The  proportion  of  male  births  increases  with 
the  age  of  the  mother.  The  maternal  and  fetal  mortalities  are 
not  excessively  high. 

Tumors  of  the  Uterus. — Fibromyoma. — The  relationship 
of  fibroids  to  pregnancy  has  already  been  considered.  Various 
complications  may  arise  in  labor,  in  association  with  submucous, 
subperitoneal,  and  interstitial  tumors.  Those  situated  near  the 
cervix  are  likely  to  cause  the  most  serious  disturbance. 
There   may  occur   displacement  of  the  cervix,  malpresentations 


TUMORS    OF   THE    UTERUS.  43 1 

and  malpositions,  hemorrhage  during  dehvery,  prolapse  of  the 
cord,  placenta  praevia,  adherent  placenta,  and  postpartum  hemor- 
rhage. Uterine  contractions  may  be  very  weak  or  irregular, 
sometimes  tetanic ;  uterine  rupture  may  occur ;  the  fetal  head 
may  be  contused  and  fractured.  Delivery  may  be  impossible  by 
natural  means.  In  the  puerperium  hemorrhage  may  occur. 
There  is  increased  liability  to  septic  infection.  Sometimes  a  fibroid 
may  become  necrosed  and  slough ;  rarely  one  may  be  expelled 
from  the  uterus. 

Diagnosis. — The  condition  is  usually  easily  ascertained,  save 
when  the  tumors  are  situated  on  the  posterior  uterine  wall  or 
project  mainly  into  the  uterus.     In  some  cases  a  fibroid  may  be 


Fig.    153. — Small   fibroid  past  which   the   child  was  extracted.      The   tumor  became 
gangrenous  and  the  woman  died  (Simpson). 

mistaken  for  parts  of  a  fetus,  for  twins,  for  fecal  masses,  or  for 
portions  of  the  placenta. 

Treatment. — Some  cases  may  go  through  labor  normally, 
especially  those  in  which  there  are  small  subperitoneal  fibroids 
situated  high  on  the  uterus.  In  other  cases,  in  which  the  tumors 
are  not  low  enough  to  obstruct  the  passage,  labor  may  be  pro- 
longed as  the  result  of  inefficient  pains.  In  these  cases  forceps 
or  version  may  be  necessary  if  the  cervix  is  dilated  ;  if  dilatation 
takes  place  slowly,  artificial  means  may  be  necessary. 

When  a  small  subperitoneal  fibroid  Hes  in  the  pelvis,  an  attempt 
may  be  made  under  anesthesia  to  push  it  above  the  brim.  If  this 
be  impossible,  the  child  may  be  delivered  by  forceps  or  version  if 
the  obstruction  caused  by  the  tumor  be  slight.     When  it  is  more 


432  ANOMALIES    OF   THE   PASSAGES. 

marked,  embryulcia  or  Csesarean  section  is  indicated.  When  a 
large  fibroid  or  several  of  small  size  cause  much  obstruction, 
Porro-Csesarean  section  is  advisable.  Pedunculated  cervical  fibroids 
may  be  removed  during  labor,  and  non-pedunculated  tumors  may 
sometimes  be  enucleated  in  order  to  remove  obstruction.  In 
every  instance  in  which  labor  takes  place  the  patient  must  be 
watched  carefully.  After  the  birth  of  the  child  it  is  advisable  to 
separate  the  placenta  manually,  in  order  to  avoid  the  risk  of  par- 
tial or  complete  non-separation  and  hemorrhage.  The  uterine 
cavity  should  be  packed  with  sterile  or  antiseptic  gauze,  which 
may  be  left  in  situ  three  days  and  renewed  if  necessary,  ergot 
being  administered  in  large  doses.  If  a  submucous  fibroid  tends 
to  become  expelled,  it  should  be  taken  away  earh',  in  order  to 
lessen  the  risk  of  infection  and  necrosis.  Sometimes  fibroids  get 
smaller  after  labor,  and  are  believed  by  many  to  disappear  occa- 
sionally. 

Anomalies  of  the  Cervix. — Displacement. — W  hen  the 
cervix  is  much  displaced,  it  may  be  a  source  of  trouble  in  labor. 
Usually  this  anomaly  is  associated  with  a  displacement  of  the 
body,  which  may  itself  be  the  cause  of  a  complicated  labor.  Some- 
times, however,  the  cervix  is  markedly  drawn  toward  one  or  the 
other  part  of  the  fornix  vaginae,  though  the  body  may  be  normally 
placed  in  the  abdomen.  Rarely,  when  the  cervix  is  drawn  far 
back  in  the  pehis,  there  may  be  a  downward  sacculation  of  the 
lower  part  of  the  anterior  uterine  wall.  Similarly,  when  the  cervix 
is  displaced  forward,  there  may  or  may  not  be  a  sacculation  of 
the  posterior  uterine  wall.  On  vaginal  examination  the  findings 
are  different,  according  to  whether  or  not  there  is  sacculation 
of  the  uterine  wall.  If  this  be  present,  the  bulging  is  felt  below 
the  level  of  the  os,  and  the  latter  may  be  distinguished  with  diffi- 
culty. Sometimes  it  is  not  felt,  and  the  projecting  sacculated 
portion  may  be  diagnosed  as  occluded  cervix  and  lower  uterine 
segment.  Sometimes,  when  the  head  fills  the  sacculated  portion, 
which  is  thinned  and  stretched  over  it,  the  diagnosis  of  fully 
dilated  cervix  may  be  made,  the  thin  uterine  wall  being  mistaken 
for  the  scalp.  The  bulging  portion  may  also  be  mistaken  for  a 
tumor.  An  anesthetic  examination  may  be  necessaiy  in  order  to 
estabHsh  a  diagnosis.  Slight  deviations  of  the  cervix  cause  no 
trouble  in  labor.  In  marked  cases  dilatation  takes  place  slowly  ; 
the  lower  uterine  segment  may  become  greatly  thinned  and  rupt- 
ure threaten.  Malpresentations  and  malpositions  of  the  fetus 
may  occur. 

Treatment. — In  many  cases  artificial  dilatation  of  the  cervix 
may  be  carried  out.  In  extreme  degrees,  especially  when  marked 
sacculation  exists,  vaginal  or  abdominal  Caesarean  section  may  be 
necessary. 

Occlusion  of  the  Os  Externum. — Atresia  of  the  cervix  occa- 


ANOMALIES   OF  THE   CERVIX. 


433 


sionally  complicates  labor.  It  may  be  partial  or  complete,  the 
latter  variety  being  very  rare.  The  affection  is  almost  entirely 
limited  to  the  os  externum.  It  may  result  from  cicatricial  con- 
traction following  operations  on  the  cervix,  sloughing,  and  the 
application  of  escharotics.  The  site  of  the  occluded  os  is  gen- 
erally marked  by  a  dimple,  through  which  a  probe  may  be  passed 
when  the  occlusion  is  not  complete.  Sometimes  the  vaginal 
portion  of  the  cervix  is  a  slight  elevation,  smooth  or  irregular,  in 
which  no  opening  can  be  found.  In  such  a  case,  if  labor  pains 
have  been  in  progress,  the  condition  may  be  wrongly  diagnosed 
as  displacement  of  the  cervix  with  sacciform  bulging  of  one  uterine 
wall  or  closure  of  the  vaginal  fornix.  If  there  be  a  head  presenta- 
tion, the  lower  segment  and  cervix  may  be  regarded  as  the  scalp, 
the  cervix  being  thought  to  be  fully  dilated.  Labor  is  greatly  de- 
layed by  such  a  condition.  Sometimes  the  cervix  may  be  opened 
without  interference.  There  is,  however,  always  risk  of  rupture 
of  the  uterus.     The  fetus  is  likely  to  be  asphyxiated. 

Treatment  should  be  carried  out  when  the  diagnosis  is  made. 
The  OS  should  be  reopened  with  a  sound  or  with  a  bistoury; 
sometimes  the  finger-tip  suffices.  Dilatation  should  then  be  carried 
out  to  a  certain  extent  with  metal  dilators  or  the  fingers.  If 
nature  cannot  complete  dilatation,  this  should  be  done  artificially, 
though  if  this  is  difficult  and  tends  to  cause  marked  laceration, 
vaginal  Caesarean  section  should  be  performed. 

Rigidity  of  the  Cervix. — This   condition   causes   difficulty   in 
dilatation  of  the  cervix.     It  may 
arise  from  peculiarities  in  its  struc- 
ture, from  pathologic  changes,  or 
from  functional  peculiarities. 

Functional  or  spasmodic  rig- 
idity or  retraction  is  believed  to 
be  due  to  abnormal  activity  in 
the  cervical  musculature,  espe- 
cially in  the  upper  or  lower 
sphincter  or  in  both.  This  con- 
dition may  be  intermittent  or 
continuous.  The  cervix  remains 
small,  or  may  contract  during 
contractions  of  the  body  instead 
of  relaxing,  and  does  not  relax 
between  the  pains.  Its  causes 
are  not  definitely  known.  It 
may  be  due  to  some  nervous  disturbance,  and  may  be  found 
in  very  nervous  women  or  in  those  who  have  been  much  dis- 
turbed by  examinations.  It  may  occur  in  cases  in  which  labor  is 
prolonged  by  some  obstruction — e.  g.,  malpresentation  and  con- 
tracted   pelvis.      Ergot  may  also   be    a    cause.      It    may  some- 


FlG.  154. — Partial  prolapse  of  womb  and 
hypertrophy  of  cervix  (Faivre). 


434  ANOMALIES    OF   THE   PASSAGES. 

times  be   associated  with   irregular  contractions    of  the   uterine 
body. 

Constitutional  Rigidity. — In  this  variety  the  cervix  is  tough 
and  dilates  with  great  difficulty.  It  is  found  in  elderly  primiparae 
and  in  cases  of  premature  labor. 

Pathologic  or  organic  rigidity  is  due  to  various  changes  in 
the  cervix,  inflammatory  cicatrization  and  thickening  being  most 
common.  These  may  result  from,  previous  labors,  operations,  or 
the  appHcation  of  escharotics.  Occasionally  syphilis  is  a  cause, 
either  the  induration  of  primary  chancre  or  changes  induced  by 
the  secondary  or  tertiary  stages  of  the  disease.  The  condition  of 
hypertrophic  elongation  of  the  cervix  is  sometimes  a  cause.  (New 
growths  of  the  cervix  are  considered  separately.)  Rigidity  of  the 
cervix,  from  whatever  cause,  leads  to  prolongation  of  labor,  with 
increase  of  suffering  to  the  woman.  Rectal  and  vesical  tenesmus 
may  be  induced,  as  well  as  nausea  and  vomiting.  After  much 
delay  dilatation  may  be  accomplished  in  many  cases.  Sometimes 
the  woman  may  become  greatly  exhausted.  The  cervix  may  be 
pushed  far  down  in  the  vagina  and  it  may  become  congested  and 
edematous.  Sometimes  the  cervix  may  rupture  ;  rarely  a  circular 
portion  may  be  torn  away.  In  some  cases  the  uterus  may  rupture 
above  the  cervix. 

Treatment. — In  the  spasmodic,  constitutional,  and  inflammatoiy 
forms  hot  douches  frequently  given  are  often  serviceable  ;  also 
chloral,  morphin,  or  opium  in  full  doses.  If  the  patient  be  ex- 
hausted, chloroform  may  be  administered,  while  one  of  these  drugs 
is  given  in  h\'podermic  injection  or  by  suppository.  In  cases  in 
which  the  contractions  of  the  uterus  are  weak  or  irregular  appro- 
priate measures  should  be  employed.  Often  artificial  dilatation  is 
necessary,  rubber  dilators  and  the  fingers  being  employed.  Re- 
cently Bossi's  metallic  dilator  has  been  recommended.  Fre- 
quently dilatation  ma}-  be  more  rapidly  performed  and  with  less 
risk  that  the  liquor  amnii  will  escape  if  the  membranes  be  detached 
a  short  distance  above  the  cervix. 

When  dilatation  cannot  be  carried  out  satisfactorily,  or  when 
it  is  apt  to  cause  much  laceration,  deliveiy  should  be  accomplished 
by  vaginal  Caesarean  section  if  the  fetus  be  alive.  If  it  be  dead, 
embryotomy  through  the  dilated  cervix  may  be  satisfactory.  The 
method  of  making  cervical  incisions  as  recommended  by  Dijhrssen 
should  not  be  adopted,  on  account  of  the  risk  of  serious  rupture  of 
the  uterus  and  hemorrhage. 

Impaction  of  the  Cervix. — The  anterior  lip  of  the  cervix  may 
be  compressed  between  the  fetal  head  and  the  pubes  in  some 
cases,  or  the  posterior  lip  between  the  head  and  the  promontory, 
resulting  in  edema  and  congestion  of  the  lower  portion  ;  as  a 
result,  a  swelling  of  considerable  size  may  be  produced,  causing 
delay  in  the  labor.     It  may  be  pushed  downward  by  the  head,  and 


ANOMALIES   OF   THE    VULVA    AND    VAGLNA.  435 

sometimes  torn  away.  In  some  cases  it  is  badly  lacerated,  verti- 
cally, obliquely,  or  transversely.  Blood  may  be  effused  in  its 
substance,  forming  a  clot.  After  labor  sloughing  sometimes 
occurs.  Occasionally  the  cervix  may  become  very  edematous 
before  labor  begins,  and  in  some  cases  the  edema  does  not  appear 
to  be  associated  with  pressure.  The  swelling  forms  a  dark-red 
tumor,  which  may  project  from  the  vulva.  It  may  be  mistaken 
for  a  fibroid,  prolapsed  uterus,  inverted  vagina,  or  placenta. 

Treatment. — The  patient  should  be  placed  in  the  dorsal  position, 
with  the  hips  higher  than  the  head.  During  pains  the  swollen 
lip  should  be  prevented  from  being  forced  downward,  and  between 
the  pains  it  should  be  pushed  upward.  Sometimes  this  may  be 
expedited  by  dilating  the  cervix,  so  as  to  allow  the  head  to  descend 
more  rapidly.  Sometimes  it  is  necessary  to  puncture  the  edema- 
tous lip,  so  that  its  size  may  be  reduced.  If  the  labor  has  been 
long  delayed,  it  is  advisable  to  extract  the  head  with  forceps,  the 
lip  being  protected  and  pushed  up  during  delivery.  Rarely  in- 
cision or  amputation  is  necessary  in  order  to  permit  extraction. 

Cancer  of  the  Cervix. — This  disease  has  already  been  de- 
scribed as  a  complication  of  pregnancy.  It  may  sometimes  be 
noticed  first  at  the  time  of  labor.  If  the  disease  be  early  and 
localized,  dilatation  may  take  place,  though  slowly,  and  labor  pro- 
ceed satisfactorily,  but  the  woman  must  be  watched  with  great 
care  lest  hemorrhage,  laceration,  or  exhaustion  occur.  If  the 
carcinoma  be  advanced,  labor  should  not  be  allowed  to  take 
place.  If  possible,  vaginal  Csesarean  section  should  be  carried 
out,  the  uterus  being  removed  after  its  contents  are  taken  away. 
The  fetus  is  extracted  in  this  operation  by  version  or  forceps  ;  but 
if  it  be  dead,  embryulcia  may  be  performed.  When  the  vaginal 
operation  is  not  feasible,  the  carcinoma  should  be  scraped  away, 
the  surface  cauterized,  and  abdominal  Porro-Caesarean  section 
carried  out. 

Anomalies  of  the  Vulva  and  Vagina. — Malformations. 
— Congenital  atresia  or  septal  remains  may  obstruct  labor.  Septa 
should  be  divided.  Atresic  portions  may  be  dilated  if  not  too 
extensive,  but  sometimes  incisions  may  be  required.  Delivery 
by  forceps,  embryulcia,  or  Csesarean   section  may  be  necessary. 

Rigidity. — The  tissues  of  the  vulva  and  vagina  may  be  rigid 
and  less  distensible  than  normal  in  young  or  old  primiparae  and 
in  cicatricial  contraction  following  previous  injury.  The  hymen 
may  sometimes  be  a  marked  cause  of  resistance  to  the  passage 
of  the  head. 

In  very  powerful  women  the  well-developed  musculature  of 
the  pelvic  floor  may  narrow  the  genital  passage,  the  levatores  ani 
being  the  most  important  factor.  They  may  easily  be  felt  to  con- 
tract spasmodically  or  continuously  by  the  examining  fingers. 
Such  conrlitions  may  delay  labor  many  hours.    In  some  cases  the 


436  ANOMALIES    OF   THE   PASSAGES. 

resistance  may  be  overcome  at  the  expense  of  the  tissue,  lacera- 
tions of  the  vulva  and  vagina  being  produced.  When  there  is 
marked  contraction  of  the  outlet,  as  in  the  case  of  a  rigid  hymen, 
central  rupture  of  the  perineum  may  occur.  Laceration  of  the 
vulva  or  vaginal  wall  may  extend  into  the  bladder,  rectum,  cervix, 
peritoneum,  or  cellular  tissue.  Marked  hemorrhage  may  be  pro- 
duced in  these  cases. 

Treatinoit. — Hot  douches  and  hot  fomentations  may  serve 
somewhat  to  soften  the  parts,  but  dilatation  under  anesthesia  is 
often  advisable.  This  procedure  may  be  carried  out  with  rubber 
bags  or  with  the  hands.  When  the  hymen  is  at  fault,  it  may  be 
necessary  to  make  multiple  incision  in  it  or  to  excise  it.  In  the 
case  of  a  rigid  perineum  it  must  always  be  remembered  that  the 
employment  of  Walcher's  position  helps  to  relax  it.  When  this 
is  not  sufficient,  episiotomy  should  be  performed.  When  the 
vagina  is  so  cicatrized  that  satisfactory  dilatation  cannot  be  carried 
out,  Caesarean  section  is  necessary. 

Hematoma. — A  localized  accumulation  of  blood  may  be  found 
in  any  part  of  the  vulva  or  vaginal  wall,  and,  though  it  is  gen- 
erally found  after  labor,  it  may  be  present  before  the  birth  of  the 
fetus.  Rarely  it  may  develop  between  the  delivery  of  the  first 
and  the  second  child  in  the  case  of  twins.  When  the  swelling  is 
large  enough  to  interfere  with  labor,  it  should  be  incised,  the  clots 
being  removed.  After  delivery  firm  pressure  may  be  applied  to 
it  by  means  of  a  tampon  placed  in  the  vagina  or  against  the 
vulva.  Sometimes  it  is  necessar)'  to  pack  the  blood-cavity  or  to 
apply  sutures  to  check  the  hemorrhage.  In  cases  of  this  kind 
it  is  advisable  to  deliver  the  fetus  with  forceps  unless  it  is  ad- 
vancing quickly  by  the  natural  powers. 

Edema. — This  condition  is  usually  found  in  heart  or  kidney 
disease,  in  delayed  labors,  and  in  marked  distention  of  the  abdomen. 
The  swollen  tissues  may  obstruct  labor,  and  may  easily  suffer  as 
a  result  of  pressure ;  they  may  afterward  become  infected  or 
gangrenous.  Puncture  or  incision  may  be  necessary  to  diminish 
the  swelling,  though  these  procedures  increase  the  risk  of  septic 
infection.  Strict  asepsis  is  necessary.  Episiotomy  is  sometimes 
indicated  in  order  that  rupture  may  be  avoided. 

Varicose  Veins. — This  condition  is  rarely  extensive  enough  to 
prevent  the  passage  of  the  fetus.  Rupture  may  occasionally  take 
place,  or  bruising,  which  may  be  followed  by  sloughing.  It  may 
sometimes  be  necessary  to  use  forceps,  and  in  all  cases  appliances 
must  be  at  hand  to  check  hemorrhage  should  rupture  occur. 

Abscess. — Suppuration  in  the  vulva  usually  starts  in  a  Bartho- 
linian  gland.  It  is  a  serious  complication  because  of  the  risk 
of  infection.  If  it  be  large  enough  to  obstruct  labor,  it  should 
be  excised,  if  possible  ;  otherwise  it  should  be  opened,  scraped, 
cauterized,  and  packed  with  antiseptic  gauze  for  two  or  three  days 


AFFECTIONS   OF   THE   BLADDER.  437 

and  then  renewed,  in  order  to  diminish  the  chance  for  the  upward 
extension  of  infection.  Moist  antiseptic  appHcations  should  be 
appKed  constantly  to  the  vulva. 

Solid  Tumors. — Fibroma  and  fibromyoma  of  the  vulva  or 
vagina  are  very  rare.  They  may  prevent  the  birth  of  the  fetus. 
When  they  are  much  bruised,  sloughing  may  afterward  follow. 
If  removal  or  enucleation  seems  feasible,  it  should  be  carried  out 
under  anesthesia.  If  not,  the  fetus  may  be  delivered  with  forceps 
if  sufficient  room  can  be  obtained  for  their  safe  employment. 
Rarely  embryulcia  or  Caesarean  section  is  indicated. 

Cystic  Swellings. — These  may  obstruct  labor,  but  the  trouble 
is  easily  overcome  by  puncture.  Removal  should  not  be  per- 
formed during  labor  save  when  the  cyst  is  pedunculated. 

Bowel  Complications. — Enterocele. — Vaginal  enterocele 
may  be  anterior  or  posterior,  the  latter  being  more  frequent. 
Labor  may  be  obstructed,  especially  when  there  is  gas  or  feces  in 
the  bowel.  Pressure  on  the  sac  may  rupture  it  or  cause  bruising 
of  the  intestine.  An  attempt  should  be  made  to  reduce  the 
hernia  by  placing  the  patient  in  the  genupectoral  or  elevated 
lithotomy  position.  The  latter  maybe  very  conveniently  arranged 
in  hospitals  by  using  a  Boldt  operating-table  with  shoulder  sup- 
ports. The  fetus  should  then  be  extracted  with  forceps  before 
the  hernia  can  descend  again.  If  the  mass  cannot  be  reduced 
owing  to  adhesions  or  to  the  low  position  of  the  fetus,  forceps 
delivery  may  be  carried  out  if  the  enterocele  be  small.  If  it  be 
large,  Caesarean  section  is  advisable. 

Distended  Rectum  or  Colon. — Fecal  accumulation  may 
directly  obstruct  the  pelvic  cavity  and  delay  labor,  or  may  inter- 
fere with  the  action  of  the  powers.  Sometimes  rectal  distention 
is  found  in  cases  in  which  the  anus  is  situated  abnormally  far 
forward  {amis  vaginalis).  The  bowel  must  be  flushed  out. 
Rarely  impacted  feces  must  be  scooped  out. 

Cancer  of  the  rectum,  if  advanced,  may  cause  such  an  ob- 
struction as  to  necessitate  embryulcia  or  Caesarean  section. 

Affections  of  the  Bladder. — Distention. — Accumulation 
of  urine  in  the  bladder  frequently  delays  labor.  The  condition  is 
very  apt  to  be  overlooked,  especially  when  frequent  dribbling 
occurs.  The  bladder  should  be  emptied  with  a  long  curved  gum- 
elastic  or  metal  catheter.  A  soft-rubber  catheter  may  fail  to 
reach  the  urine,  while  a  glass  instrument  may  easily  be  broken. 

Cystocele. — Prolapse  of  the  bladder  and  anterior  vaginal  wall 
may  obstruct  labor.  The  condition  may  be  mistaken  for  an  im- 
pacted and  swollen  anterior  lip  of  the  cervix,  the  bag  of  mem- 
branes, caput  succedaneum,  or  cy.st  of  the  vaginal  wall. 

In  labor  special  care  should  be  taken  to  keep  the  bladder 
empty.  In  the  second  stage  the  prolapsing  part  should  be  pre- 
vented from  descending,  and  if  possible  should  be  gradually  pushed 


438 


ANOMALIES    OF   THE    PASSAGES. 


upward  as  the  head  descends.     When  labor  proceeds  slowly,  it  is 
best  to  deliver  the  fetus  with  forceps. 

Stone  in  the  Bladder. — A  small  calculus  may  not  obstruct 
labor,  but  if  it  be  pushed  against  the  pubes  by  the  advancing  head, 
it  may  injure  the  bladder-wall.     Several   calculi,  or  one  of  some 


Fig.  155. — Ovarian  tumor  incarcerated 
in  pelvis  during  labor. 


^6. — Cystocele    obstructinc 
labor. 


size,  may  be  an  obstruction.  When  this  is  likely  to  take  place,  the 
stone  should  be  removed  through  the  dilated  urethra  or  through 
an  opening  made  in  the  base  of  the  bladder  and  anterior  vaginal 
wall.     After  labor  the  fistula  may  be  closed. 

Affections  of  Neighboring  Parts. — Ovarian  Tumors. — 
These  have  already  been  fully  considered  in  connection  with  preg- 
nancy (p.  338).  They  may  complicate  labor  by  interfering  with 
the  normal  action  of  the  powers  and  by  obstructing  the  birth 
passage.  They  cause  malpresentations  and  malpositions.  When 
a  small  tumor  lies  in  the  pelvis  it  may  absolutely  prevent  deliver>^ ; 
it  may  be  much  compressed  and  injured  or  may  rupture.  The 
pedicle  may  become  twisted  and  obstruction  of  the  bowel  be  pro- 
duced. Peritonitis  or  hemorrhage  may  foHow.  The  obstruction 
may  sometimes  cause  rupture  of  the  uterus,  vagina,  or  bowel. 

The  diag-nosis  may  be  difficult.  The  tumor  may  be  mistaken 
for  a  fibroid,  inflammatoiy  or  blood-accumulation,  ectopic  preg- 
nancy, or  fecal  mass.  When  the  abdomen  is  much  distended, 
hydramnios  or  twin  pregnancy  may  be  thought  to  exist.  It  is 
important  to  note  that  no  intermittent  contractions  can  be  felt  in 
the  tumor. 

Treatment. — If  the  tumor  be  small  and  situated  below  the 
pelvic  brim,  or  large  and  above  the  brim,  C?esarean  section  should 
be  performed  and  the  tumor  removed  at  the  same  time.  Hitherto 
it  has  been  recommended  that  small  tumors  below  the  brim  should 
be  pushed  above  it,  or,  failing  this,  to  deliver  the  fetus  with  forceps 


'AFFECTIONS   OF   THE   NEIGHBORING   PARTS.  A^-^^c^ 

or  by  embryulcia,  the  tumor  being  punctured  per  vaginam  if  nec- 
essary to  secure  room.  Such  a  procedure  should  be  employed 
only  where  abdominal  section  cannot  be  safely  carried  out.  It 
has  been  demonstrated  to  be  more  risky  for  the  woman  than  is  the 
latter  procedure.  Compression  of  a  tumor  lying  in  the  pelvis  may 
lead  to  rupture,  hemorrhage,  peritonitis,  and  gangrene.  A  tumor 
situated  above  the  brim  may  become  changed  in  position,  its 
pedicle  twisting  and  leading  to  edema,  hemorrhage,  gangrene,  and 
peritonitis.  If  adhesions  are  present,  they  may  be  ruptured.  More- 
over, a  tumor  in  the  abdomen  may  interfere  with  the  uterus  after 
labor,  preventing  it  from  sinking  as  it  normally  does,  and  may 
cause  postpartum  hemorrhage. 

Other  Pelvic  Swellings. — Tumors,  collections  of  blood,  pus,  or 
serum  in  the  tubes,  broad  ligaments,  or  other  tissues,  sufficient  to 
obstruct  labor  seriously,  are  indications  of  Caesarean  section  when 
it  is  certain  that  evacuation  cannot  be  carried  out  by  the  vagina 
without  exposing  the  woman  to  the  risk  of  hemorrhage  or  infection. 

Inguinal  and  Femoral  Hernias. — A  hernia  may  be  forced 
down  during  the  straining  connected  with  labor  and  may  be  a 
cause  of  much  pain  ;  sometimes  strangulation  results.  The  hernia 
should  be  held  up  during  the  pains.  In  such  cases  it  is  advisable 
to  anesthetize  the  woman  and  deliver  the  fetus  by  version  or 
forceps  as  soon  as  the  cervix  is  dilated. 

Hepatic  and  other  Abdominal  Swellings. — Hydatid  cysts, 
malignant  tumors,  and  enlarged  spleen  may  obstruct  or  delay 
labor.  Forceps,  version,  embryulcia,  or  Caesarean  section  may 
be  necessary. 

Displaced  Kidney. — A  normal  or  enlarged  kidney  may  some- 
times be  displaced  downward  so  as  to  obstruct  the  birth  passage 
at  the  pelvic  brim  or  in  the  cavity.  The  displacement  may  be 
congenital  or  may  be  due  to  a  floating  condition.  In  the  former 
case  the  kidney  is  not  movable  and  has  a  short  ureter.  Accord- 
ing to  Morris,  a  pelvic  kidney  (apart  from  pregnancy)  is  found  once 
in  800  cases,  floating  kidney  being  more  common  on  the  right 
side  and  congenital  pelvic  kidney  on  the  left.  Only  a  few  cases 
of  labor  complicated  by  the  misplaced  kidney  have  been  recorded. 
Very  great  pain  may  be  caused  in  these  cases.  Rupture  of  the  uterus 
has  resulted  from  the  obstruction.  The  kidney  may  be  much 
damaged  by  pressure.  Anesthesia  and  forceps  delivery  have  been 
recommended,  though  this  procedure  may  lead  to  injury  of  the 
kidney.  Abdominal  section  has  also  been  performed ;  this  is 
probably  the  mo.st  satisfactory  procedure.  The  kidney  might  be 
raised  out  of  the  pelvis,  the  abdomen  closed,  and  the  fetus  de- 
livered by  version  or  forceps. 

If  the  kidney  be  wedged  in  the  pelvis  or  adherent,  Caesarean 
section  is  necessary.  Vaginal  nephrectomy  has  been  performed 
in  this  condition,  but  such  a  step  seems  unwarranted. 


440  ANOMALIES   OF  THE  BONY  PELVIS. 

CHAPTER    III. 
ANOMALIES  OF  THE  BONY  PELVIS. 

Pelvic  Deformities. — Many  variations  from  the  normal  type 
of  pelvis  are  found,  the  most  important  of  which,  as  regards  their 
influence  on  labor,  are  contractions.  These  complicate  labor  in 
various  ways  and  may  make  it  a  difficult  or  dangerous  process, 
both  for  the  mother  and  child,  very  often  necessitating  artificial 
interference. 

During  pregnancy  various  irregularities  may  occur ;  thus,  in 
the  early  months  marked  anteroposterior  contraction  of  the  pelvic 
brim  may  cause  the  growing  uterus  to  be  deflected  backward,  so 
that  a  retroverted  condition  of  the  organ  is  brought  about,  and  as 
pregnancy  advances  the  uterus  may  become  incarcerated  in  the 
pelvic  cavity.  In  the  advanced  months  the  uterus  does  not  sink 
as  low  as  in  normal  cases,  so  that  the  abdomen  becomes  abnor- 
mally prominent.  When  the  fundus  remains  abnormally  high,  the 
round  ligaments  are  tenser  than  usual.  If  the  abdominal  parietes 
be  lax,  marked  displacement  of  the  body  of  the  uterus  anteriorly 
or  laterally  may  result.  At  full  time  malpresentations  and  mal- 
positions are  three  times  as  frequent  as  in  normal  cases,  the  pro- 
portion being  greater  in  multiparje  than  in  primiparse,  owing  to 
the  greater  relaxation  of  the  abdominal  walls. 

Franke's  researches  indicate  that  in  cases  of  contracted  pelves 
more  primiparas  than  multiparae  are  delivered  spontaneously,  ex- 
cluding all  causes  of  delay  not  directly  due  to  the  pelvic  con- 
traction, which  are  undoubtedly  more  apt  to  be  found  in  multip- 
arous  labors.  This  is  probably  due  to  greater  strength  of  the 
pains,  the  tendency  to  early  engagement  of  the  head,  the  absence 
of  uterine  deviations,  the  smaller  size  of  the  fetus,  and,  possibly, 
the  less  advanced  ossification  in  primiparse. 

In  the  first  stage  of  labor  in  cases  of  marked  contraction  various 
anomalies  may  be  found  :  the  cervix  is  higher  than  normal,  the 
diminished  pelvic  inlet  may  not  allow  the  presenting  part  of  the 
fetus  to  descend  well  into  the  lower  uterine  segment,  and  the 
cervix  may  thus  be  made  to  hang  somewhat  loosely  at  or  above 
the  brim.  This  anomaly  is  most  marked  when  some  malpresen- 
tation  is  present — c.  g.,  transverse.  There  may  be  weak  and 
irregular  pains  for  hours,  or  even  days,  before  the  cervix  begins 
to  dilate. 

As  the  pains  continue  dilatation  of  the  cervix  may  be  very  slow, 
the  normal  distention  of  the  lower  uterine  segment  by  the  bag  of 
membranes  may  be  absent,  and  the  latter  may  be  forced  through 
the  cervix  as  an  elongated  pouch. 


PELVIC  DEFORMITIES.  44 1 

Not  infrequently  the  membranes  rupture  prematurely,  leading- 
to  great  prolongation  of  the  first  stage  and  retraction  of  the 
uterus  on  the  fetus,  increasing  the  risk  both  to  the  mother  and 
fetus.  The  cord  frequently  prolapses  into  the  lower  uterine  seg- 
ment or  through  the  cervix — occurring  four  times  as  frequently 
in  flat  as  in  normal  pelves. 

In  such  cases,  if  the  labor  be  allowed  to  continue  long  enough 
and  the  pelvic  contraction  be  not  too  great,  the  fetus  may  be 
expelled  dead,  the  head  being  much  altered  by  moulding  and 
softening,  fractures  of  its  bones  being  sometimes  present.  If  the 
contraction  be  too  great  to  allow  the  fetus  to  pass,  there  is  great 
risk  of  rupture  of  the  uterus  or  of  exhaustion  of  the  mother.  The 
lower  uterine  segment  thins  and  the  retraction  ring  tends  to  rise. 
Apart  from  rupture,  the  maternal  soft  parts  may  be  injured  by 
prolonged  pressure,  and  this  maybe  followed  by  necrosis  of  the  tis- 
sues. The  risk  of  infection  in  such  conditions  is  also  considerable. 
The  risks  to  the  fetus  are  great,  owing  to  compression  of  the 
prolapsed  cord,  retraction  of  the  uterus  on  the  fetus  causing  inter- 
ference with  the  circulation  in  the  cord  or  placenta,  as  well  as  to 
difficulties  associated  with  the  various  methods  of  artificial  de- 
livery which  may  be  adopted. 

Pinard  has  stated  that  the  average  weight  of  infants  born  to 
women  with  contracted  pelves  is  greater  than  in  the  case  of  women 
with  normal  pelves. 

Frequency. — It  is  difficult  to  form  an  accurate  idea  of  the 
frequency  of  pelvic  deformities,  owing  to  the  imperfect  methods 
of  examination  adopted  in  ordinary  practice,  and  also  to  the  dif- 
ference of  opinion  among  experts  as  to  what  constitutes  a  pelvic 
deformity.  Some  observers  include  in  the  classification  slight 
anomalies  that  others  exclude.  Many  tabulate  only  alterations 
that  cause  serious  trouble  in  labor.  It  is  usually  believed  that 
deformities  are  much  more  common  in  the  Old  World  than  in 
America.  As  the  result  of  the  recent  observations  of  Williams 
and  Dobbin,  these  views  must  be  considerably  modified.  These 
observers  state  that  pelvic  deformities  are  rarer  in  America  only 
because  they  are  not  sought  for  by  careful  examination  of  preg- 
nant and  parturient  women. 

In  looo  cases  studied  by  them,  13.10  per  cent,  of  the  pelves 
were  contracted,  and  of  these  contracted  pelves,  35.11  per  cent, 
were  affected  to  such  an  extent  as  to  require  artificial  delivery. 
They  have  also  shown  that  the  statistics  of  Reynolds,  of  Boston, 
are  not  reliable  as  regards  the  determination  of  the  frequency  of 
deformed  pelves,  since  this  observer  made  measurements  only  in 
the  cases  in  which  artificial  delivery  was  carried  out.  They  showed 
that  such  a  method  of  inquiry  is  certain  to  result  in  the  non- 
recognition  of  a  considerable  percentage  of  deformities. 

In  their  comparison  of  white  and  negro  women  they  found 


442  ANOMALIES    OF   THE   BONY  PELVIS. 

that  contractions  are  much  more  frequent  among  the  latter, 
though  the  proportion  of  difficult  labors  among  negresses  is 
small  on  account  of  the  smaller  and  easily  moulded  fetal  head. 

E.  P.  Davis,  in  studying  1224  women,  found  that  25  per  cent, 
had  contracted  pelves.  Edgar  found  in  1200  cases  3.66  per  cent, 
of  contracted  pelves.  In  2.5  per  cent,  the  contraction  was  justo- 
minor,  and  in  1. 16  per  cent.  flat. 

As  regards  the  statistics  of  other  countries,  great  variations 
are  found.  Winckel  states  that  contracted  pelves  occur  in  12  or 
15  per  cent,  of  child-bearing  German  women,  but  that  in  only  5 
per  cent,  is  the  contraction  important  enough  to  attract  attention. 

As  regards  the  percentage  of  artificial  interference  in  deformed 
pelves,  different  statements  are  also  made.  Knapp  puts  it  at  61 
per  cent.,  Heinsius  at  56.84  per  cent.,  Ludvig  and  Savor  at  45.6 
per  cent.,  Bosmann  at  24.5  per  cent.,  and  Franke  at  20.5  per  cent. 
The  largest  percentage  given  in  America  is  that  of  Flint,  who 
puts  it  at  46  per  cent.  In  Davis's  cases  operations  were  performed 
in  20  per  cent,  of  patients  with  abnormal  pelves. 

Classification. — Various  methods  of  classifying  deformed 
pelves  are  found.  The  following  will  be  found  satisfactory  in 
teaching : 

I.  Peh'es  normal  in  proportion  but  abnormal  in  size. 

1.  Uniformh^  contracted — squabiliter  justo-minor. 

2.  Uniformly  enlarged — aequabiliter  justo-major. 

II.  Pelves  with  anomalies  of  size,  shape,  and  inclination,  or 
combinations  of  these. 

1.  Those  with  minor  developmental  peculiarities — /.  c,  shallow, 
deep,  funnel-shaped,  or  masculine. 

2.  Contraction  in  the  anteroposterior  diameter,  {a)  Flat  non- 
rachitic,     {b)  Flat  rachitic,     {c)  Spondylolisthetic. 

3.  Contraction  in  an  oblique  diameter,  {a)  As  a  result  of  loss 
of  one  leg,  or  impaired  use  of  one  leg  in  early  hfe.  {b)  K'S,  a 
result  of  imperfect  development  of  one  sacral  ala  (Naegele  pelvis). 

4.  Contraction  in  the  transverse  diameter.  As  a  result  of  im- 
perfect development  of  both  sacral  alse  (Robert  pelvis). 

5.  Generally  compressed  pelves.  (<^)  Malacosteon.  ((^)  Pseudo- 
malacosteon-rachitic. 

6.  Contraction  associated  with  deformities  of  the  spinal  column. 
{a)  Kyphosis.     (/;)  Scoliosis,     (r)  Kyphoscoliosis,    [d)^  Lordosis. 

7.  Alterations  of  the  pelvis  resulting  from  tumors,  injury,  and 
disease. 

The  contractions  that  most  frequently  give  rise  to  difficulty  in 
labor  are  the  follo\Ving:  the  justo-minor  and  flat  pelves;  less 
frequent  are  the  alterations  produced  by  spinal  deformities,  and 
those  presenting  developmental  peculiarities — /.  e.,  masculine  and 
funnel-shaped. 

Diagnosis. — In  attempting   to  determine  the  condition   of  a 


PEL  VIC  DEFORMITIES. 


443 


woman's  bony  pelvis  it  is  necessary  to  investigate  the  previous 
healtli  of  tiie  patient,  to  gain  accurate  information  regarding  her 
previous  pregnancies  and  labors,  and  to  make  a  thorough  physical 
examination  of  the  pelvis,  accurate  measurements  being  taken. 

If  the  woman  be  in  labor,  a  study  of  the  mechanism  of  deUvery 
may  give  important  information,  while  after  the  birth  of  the  child 
the  moulding  of  its  head  as  well  as  the  relation  of  the  uterus  to 
the  bony  canal  may  give  additional  facts. 

In  determining  the  previous  history  the  health  during  infancy 
and  childhood  should  be  inquired  into.  If  she  had  been  affected 
with  rickets,  the  history  might  be  obtained  from  the  patient's 
mother  of  digestive  disorders,  peevishness,  late  dentition,  restless- 
ness and  sweating  during  sleep,  and  late  closure  of  the  anterior 
fontanel ;  in  such  cases  various  changes  in  the  bones  may  have 
been  noted — t^-g-,  bending  of  the  long  bones,  enlargement  of  their 


Fig.  157. — Schultze's  pelvimeter. 

ends,  deformity  of  the  spinal  column,  small  stature,  square  head, 
pigeon-breast,  rosary-ribs,  etc. 

If  a  history  of  tuberculosis  is  given,  it  is  important  to  find  out 
whether  the  spine,  joints  of  the  pelvis,  or  lower  extremities  have 
been  affected,  since  these  lesions  may  secondarily  induce  pelvic 
deformities.  Investigation  should  also  be  made  as  to  accidents 
causing  shortening,  dislocation,  long  disuse  or  loss  of  the  lower 
extremities  ;  rarely  accident  is  the  cause  of  dislocation  of  the 
lumbar  vertebrae  from  the  sacrum.  Occasionally  deformities  are 
associated  with  congenital  anomalies — e.g.,  congenital  dislocation 
of  one  or  both  hips.  Rarely  the  patient  may  have  suffered  from 
osteomalacia,  the  history  in  such  a  case  being  one  of  poverty, 
hard  work,  imperfect  nutrition,  and  exposure,  the  disease  having 
developed  during  pregnancy  or  nursing.  In  a  number  of  cases 
pelvic  contraction  is  found  in  women  who  may  have  had  no  dis- 


444 


ANOMALIES   OF   THE   BONY  PELVIS. 


tinct  disease  during  early  life,  but  who  have  been  weak,  inactive^ 
and  slow  of  growth. 

Pelvimetry. — In  determining  the  size  of  the  pelvis,  some  in- 
formation may  be  obtained  by  the  use  of  the  eyes  and  hands,  but 
to  get  exact  measurements  instruments  are  necessary.  Efforts 
have  been  made  to  use  the  ,t--rays  in  pelvimetry,  but  without  very 
satisfactory  results. 

{a)  External   Measurements. — In   measuring   the    pelvis  ex- 


FlG.  158. — Measuring  external  conjugate  diameter  upon  living  female  (Dickinson). 


ternally  a  measuring-tape  may  be  used,  but  it  is  of  very  limited 
value.  A  pair  of  cahpers  is  necessary.  Baudelocque,  in  1775,, 
first  recommended  this  instrument,  which  has  been  termed  a  pel- 
vimeter. Several  varieties  have  been  introduced,  but  that  intro- 
duced by  Baudelocque  is  as  satisfactory  as  any. 

I.  External  Conjugate,  Anteroposterior.  —  Baudelocque  first 
called  attention  to  the  importance  of  estimating  the  size  of  the 
pelvic  cavity  by  making  an  anteroposterior  measurement  on   the 


PEL  VIME  TR  V. 


445 


living  person  in  the  plane  of  the  pelvic  brim.  This  has  since  been 
known  as  the  external  conjugate  or  diameter  of  Baudelocque.  He 
believed  that  by  subtracting  from  this  diameter  that  which  repre- 
sents the  thickness  of  bones  and  soft  tissues,  an  exact  idea  of  the 
length  of  the  conjugata  vera,  or  anteroposterior  diameter  of  the 
pelvic  inlet,  might  be  obtained.  His  measurement  was  made 
between  the  depression  below  the  spine  of  the  'last  lumbar 
vertebra  and  the  top  of  the  symphysis  pubis,  and  he  estimated 
the  thickness  of  bones  and  soft  tissues  to  be  subtracted  at  8  to 
8.5  cm. 

To  obtain  Baudelocque's  diameter  the  patient  is  placed  on  her 
side,  the  hips  being  exposed.  The  physician  stands  behind  her, 
facing  her  head,  the  pelvimeter  in  his  hands  so  that  the  tip  of 
each  index-finger  is  on  the  end  of  each  rod  ;  he  places  the  latter 
points  in  the  anatomic  positions  above  indicated.  He  then  reads 
off  on  the  scale  attached  to  the  instrument  the  length  of  the 
measurements.     If  no  scale   is   attached   to   the  instrument,   an 


Fig.  159. — Faraboeuf  s  method  of  measuring  the  conjugata  vera. 

assistant  may  be  employed  to  fix  the  rods  in  position,  so  that  the 
pelvimeter  may  be  removed  and  the  distance  between  the  ends  of 
the  rods  measured.  If  the  last  lumbar  spine  cannot  be  easily 
felt,  an  endeavor  should  be  made  to  find  the  lateral  angles  of  the 
lozenge  of  Michaelis  (posterosuperior  iliac  spines).  A  line  should 
be  drawn  between  these  and  a  point  measured  3  to  4  cm.  verti- 
cally above,  in  the  middle  line.  This  corresponds  to  the  de- 
pression below  the  last  lumbar  spine.  Crede  suggested  that  in 
cases  where  the  posterior  markings  are  absent,  an  imaginary  line 
should  be  drawn  through  the  highest  points  of  the  ijiac  crests,  the 
depression  below  the  spine  of  the  last  lumbar  vertebra  being  2  to 
3  cm.  below  this  line. 

The  value  of  this  measurement  as  a  means  of  determining  the 
brim  conjugate  is  not  now  highly  considered.  The  external  con- 
jugate and  the  conjugata  vera  do  not  lie  in  the  same  plane. 
The  former  crosses  the   other,   passing  posteriorly,  not  through 


446 


ANOMALIES   OF  THE  BONY  PELVIS. 


the  promontory,  but  through  the  body  of  the  first  sacral  ver- 
tebra. The  thickness  of  bones  and  soft  tissues  varies  so  greatly 
that  it  cannot  be  carefully  estimated  in  any  given  case.  Litzmann 
measured  the  pelvis  in  30  cases  before  and  after  death  and  found 
an  average  difference  between  the  true  and  external  conjugates  of 
9.5  cm.  (3!^  in.) ;  in  the  whole  series  the  range  was  from  7  cm. 
(2f  in.)  to  12.5  cm.  (4Min.). 

Undoubtedly  in  some  cases  the  conjugate  of  Baudelocque  may 
indicate  positively  pelvic  contraction,  and  in  other  cases  equally 
positively  the  absence  of  contraction.  In  many  cases,  however, 
no  accurate  information  as  to  the  size  of  the  conjugata  vera  can 
be  derived  from.it.  Jewett  says  that  the  pelvis  is  invariably  con- 
tracted when  the  external   conjugate  is  at  or  below  15.2  cm.  (6 


Fig.  160. — Hirst's  pelvimeter:   A,  For  measuring  true  conjugate  plus  thickness  of  sym- 
physis; B,  with  extra  tip  added  for  measuring  thickness  of  symphysis. 


in.),  or  even  below  15.8  cm.  (6^  in.) ;  at  or  above  20.3  cm.  (8  in.) 
the  pelvis  is  surely  ample  ;  between  6^  and  8  in.  the  length  of  the 
conjugata  vera  is  uncertain  and  must  be  determined  by  other 
measurements.  The  conjugata  vera  maybe  estimated  by  external 
measurements  in  another  manner  in  a  thin  woman  who  is  not 
pregnant,  or  whose  pregnant  uterus  may  not  rise  above  the  brim. 
When  she  lies  on  her  back,  the  examiner's  hand  is  placed  flat 
above  the  pubes,  the  abdominal  wall  being  pressed  back  against 
the   promontory  by   the  finger-tips.     The   distance  between  the 


PEL  VI ME  TR  Y.  44/ 

latter  and  the  symphysis  pubis  is  thus  measured,  and  the  thick- 
ness of  the  abdominal  wall  and  other  soft  tissues  deducted. 

2.  Anteroposterior  Conjugate  of  the  Outlet. — The  distance  from 
the  lower  edge  of  the  symphysis  to  the  lower  end  of  the  sacral 
or  coccygeal  vertebrae  may  be  made  with  a  pelvimeter,  a  slight 
deduction  being  made  for  the  thickness  of  soft  tissues. 

This  measurement  may  also  be  made  by  vaginal  examination 
with  the  extended  fingers. 

3.  Transverse. — The  following  measurements  are  usually  made 
and  are  important : 

(a)  Interspino7is,  anterior — between  the  anterosuperior  iliac 
spines. 

{b)  Intercristal — between  the  widest  parts  of  the  summits  of  the 
iliac  crests. 

[c]  Interspinoiis,  posterior — between  the  posterosuperior  iliac 
spines  (lateral  angles  of  Michaelis's  lozenge). 

(</)  Intertrochanteric — between  the  skin  surfaces  external  to  the 
great  trochanters.  This  measurement  is  not  reliable,  owing  to 
variations  in  the  size  of  the  head,  neck,  and  trochanter  of  the 
femur.  If,  however,  it  be  less  than  11^  in.,  there  is  probably 
transverse  contraction  of  the  pelvis. 

{e)  Transverse  of  the  Outlet. — The  distance  between  the  tuber- 
osities may  be  measured  with  a  pelvimeter;  or  the  examiner  may 
place  two  fingers  on  the  inner  edges,  the  distance  between  being 
measured  with  a  rule  or  piece  of  tape  by  an  assistant. 

4.  Oblique. — The  various  measurements  made  to  determine 
oblique  diameters  of  the  pelvis  are  given  in  the  section  describing 
the  Oblique  Pelvis. 

5.  Lozenge  of  Michaelis. — The  shape  and  size  of  this  area 
should  always  be  noted,  as  variations  from  the  normal  are  pro- 
duced by  many  abnormalities  and  deformities  of  the  bony  pelvis. 
(In  the  average  normal  Caucasian  woman  the  four  sides  and  angles 
are  nearly  equal.)  The  transverse  diameter  is  slightly  longer  than 
the  vertical,  and  measures  about  9.8  cm.  (3I  in.). 

(l?)  Internal  Measurements. — Digital  examination  may  give  a 
fairly  correct  idea  of  the  size  of  the  pelvic  cavity  and  outlet,  the 
height  of  the  symphysis,  the  mobility  of  the  coccyx,  etc.  Certain 
specific  measurements  must  also  be  made. 

I.  Conjugata  Diagonalis. — The  diagonal  conjugate  is  measured 
from  the  promontory  to  the  subpubic  ligament.  In  determining 
this  the  patient  should  be  placed  in  the  dorsal  position  with  the 
legs  separated.  The  examiner  passes  the  first  two  fingers  of  one 
hand,  extended,  into  the  vagina  until  the  tip  of  the  second  finger 
touches  the  promontory.  The  radial  side  of  the  hand  is  placed 
against  the  subpubic  ligament,  and  a  mark  is  made  at  this  point 
with  the  free  hand.  The  fingers  are  then  withdrawn,  being  kept 
in  the  same  position  in  which  they  were  in  the  vagina,  and  the 


448 


ANOMALIES   OF   THE  BONY  PELVIS. 


distance  between  the  tip  of  the  second  finger  and  the  point  that 
touched  the  subpubic  hgament  measured  with  a  pelvimeter  by  an 
assistant.  This  measurement  represents  the  length  of  the  diagonal 
conjugate.  In  obtaining  it  there  may  be  difficulty  in  touching  the 
promontory  if  the  patient  strains,  if  the  soft  parts  are  rigid,  if  the 
pelvis  is  deep,  or  the  promontory  high  or  far  back.  When  the 
condition  of  double  promontory  exists,  due  to  an  abnormal  pro- 
jection of  the  junction  of  the  first  and  second  sacral  vertebrae,  the 


Fig.  i6i. 


-Manual  method  of  measuring  diagonal  conjugate:    P,   Promontory;  PB, 
perineal  body  displaced  backward  (Dickinson). 


latter  may  be  mistaken  for  the  true  promontory.  In  some  cases, 
however,  it  is  nearer  the  symphysis  than  the  true  promontory, 
and  the  obstetric  conjugate  must  be  measured  in  reference  to  it. 
Sometimes  the  patient  must  be  anesthetized  before  the  examina- 
tion can  be  satisfactorily  made. 

It  is  important  to  remember  that  the  length  of  the  conjugata 
vera  as  well  as  that  of  the  conjugata  diagonalis  varies  according 
to  the  position  of  the  patient.     Each  is  greatest  in  the  Walcher 


PELVIMETRY. 


449 


posture,    and    least   when    the    thighs    are    well    flexed    on    the 
abdomen. 

The  transverse  diameter  cannot  be   directly  measured  in  the 
living  woman  per  vaginani,  but  Sandstein  has  shown  that  in  all 


Fig.  162. — Measuring  true  conjugate,  plus  thickness  of  symphysis,  with  Hirst's  pel- 
vimeter. 

classes  of  pelves  it  equals  half  the  length  of  the  intercristal  diam- 
eter. He  states  that  for  practical  purposes  deviations  from  this 
relationship  may  be  disregarded.  The  relationship  does  not  exist 
in  the  fetus. 


Fig.  163. — Measuring  thickness  of  symphysis  with  Hirst's  pelvimeter. 


2.  Ldhlei7i's  Mcasureme7it ;  from  the  Subpubic  Ligame?it  to  the 
Upper  Anterior  Angle  of  the  Great  Sacrosciatic  Notch. — This  is 
stated  to  be  normally  2  cm.  (|  in.)  less  than  the  transverse  diameter 
of  the  brim. 

29 


450  ANOMALIES    OF   THE   BONY  PELVIS. 

3.  Hirsfs  Measurement ;  from  the  Promontory  to  the  Skin  in 
Front  of  the  Upper  Part  of  the  Symphysis. — This  is  made  with  a 
special  pelvimeter,  consisting  of  a  long  straight  rod  that  is  intro- 
duced into  the  vagina  and  pressed  against  the  promontory,  and  a 
short  curved  rod  that  touches  the  front  of  the  symphysis.  When 
the  rods  are  in  position,  they  are  fixed  by  a  screw ;  the  instrument 
is  then  withdrawn  and  the  distance  between  the  ends  of  the  rods 
ascertained.  The  thickness  of  the  upper  part  of  the  symphysis 
and  soft  tissues  in  front  of  it  is  then  measured  with  small  curved 
rods  adjusted  on  the  same  instrument,  and  is  subtracted  from  the 
first  measurement  to  give  the  length  of  the  conjugata  vera.  This 
diameter  can  be  most  satisfactorily  measured  by  this  method. 


--^ 

mmmek 

Hi||yi|ii^^^.  ■  V ,  ^ 

^^- 

1 

> 

►- 

^ 

*^ 

,^ 

s^^jp 

1 

w 

Fig.  164. — Measurement  of  anteroposterior  diameter  of  outlet  (Bumm). 

The  anteroposterior  and  transverse  diameters  of  the  outlet  may 
be  measured  with  fingers  or  instruments. 

Detailed  Study  of  Individual  Pelves. — L  Pelves  Normal 
in  Proportion  but  Abnormal  in  5ize. —  i.  Normally  Co?itraeted 
{yEquabiliter  Jiisto-minor). — These  pelves  differ  from  the  normal 
female  pelvis  only  in  the  matter  of  size.  In  the  variety  most 
frequently  met  with  there  is  simply  a  general  reduction  in  the 
diameters,  the  diminution  being  proportionate.  The  vertical  con- 
cavity of  the  sacrum  is  usually  less  marked  than  that  of  the 
normal  pelvis,  the  axis  of  the  cavity  being  consequently  less 
curved  than  that  of  the  normal.  This  form  of  pelvis  may  be 
found  in  women  who  are  of  slight  build,  but  may  also  occur  in 
those  of  normal  size,  and  occasionally  even  in  large  women. 
Other   varieties    of   justo-minor   pelvis    are    described    by    some 


PLATE    II. 


Fig.  I.  —  I'lU  igi^iih  :   a    Registering  portion  ;  b,  marker  ;  c,  thumb-screw  ;  d,  spirit- 
level  ;  e,  exploring  rod. 


Fig.  2. — Kliseometer  :  a.  Rigid  arch  ;  b,  knob  at  end  of  arch  ;  c,  cylindrical  carrier  ; 
d,  end  of  rod  which  moves  through  the  carrier  ;/,  thumb-screw  ;  g,  spirit-level  ; 
h,  pointer. 

Ehrenfest  and  Neumann  have  recently  devised  two- instruments,  termed  respec- 
tively the  "pelvigraph"  (Plate  II,  Fig.  i)  and  the  "kliseometer"  (Plate  ii,  Fig.  2), 
for  the  purpose  of  determining  the  internal  dimensions,  the  configuration,  and  the 
inclination  of  the  pelvis.  Satisfactory  results  may  be  obtained  if  the  pelvis  admits 
of  manual  exploration,  if  the  woman  can  be  kept  absolutely  quiet,  and  if  the  instru- 
ments be  used  by  two  skilled  obstetricians  who  have  been  trained  to  work  together. 
The  pelvigraph  consists  of  an  exploring  rod  and  a  registering  arm  attached  to  a 
marker.  When  the  woman  lies  on  her  back  with  the  feet  elevated,  the  exploring 
rod  is  introduced  into  the  vagina.  In  determining  the  true  conjugate,  for  example, 
the  end  of  the  rod  is  brought  into  contact  with  the  upper  edge  of  the  posterior 
surface  of  the  symphysis.  The  registering  arm,  with  its  marker,  is  manipulated  by 
an  assistant,  a  point  iaeing  made  on  a  sheet  of  paper  representing  that  portion  of  the 
.symphysis  touched  by  the  exploring  rod.  The  latter  is  withdrawn  and  another  rod 
is  attached,  suitable  for  application  to  the  promontory.  When  the  latter  is  touched, 
a  corre.sponding  mark  is  made  on  the  paper,  and  the  distance  between  the  two  marks 
represents  the  length  of  the  true  conjugate. 

By  the  simple  mechanical  contrivance  of  a  movable  spirit-level  attached  to  the 
registering  arm,  the  distances  between  the  points  indicated  by  the  marker  can  be 
made  to  represent  exactly  those  touched  by  the  exploring  rods. 

In  using  the  kliseometer  to  determine  the  inclination  of  ihe  pelvis,  the  woman 
stands  erect,  the  toes  and  heels  being  close  together. 

A  Complete  account  of  the.se  instruments  and  of  the  method  of  using  them  is 
givffn  by  Elirenfest  in  the  American  Journal  of  Obstetrics,  vol.  xlvii..  No.  5,  1903. 


DETAILED   STUDY  Of  INDIVIDUAL   PELVES. 


451 


authors,  but  are  rarely  found.  They  are  the  infantile  form,  in 
which  some  of  the  characteristics  of  the  pelvis  of  the  child  are 
retained,  and  a  dwarf  form,  in  which  the  bones  are  light  and 
fragile,  the  cartilaginous  junctions  being  retained  between  the 
pubes,  ischium,  and  ilium. 

Etiology. — In  some  cases — /.  c,  dwarfs — the  diminished  size  of 
the  pelvis  is  part  of  a  general  non-development.  In  the  majority 
of  cases,  however,  it  is  impossible  to  estabHsh  any  such  associa- 


FlG.  165. — Posterior  aspect  of 
woman  with  normal  pelvis.  The 
lozenge  of  Michaelis  is  well  shown 
(Bumm). 


Fig.  166. — Posterior  aspect  of 
woman  with  justo-minor  pelvis. 
The  small  lozenge  of  Michaelis  is 
shown  (Bumm). 


tion  ;  it  is  by  some  attributed  to  impairment  of  health  from  any 
condition  in  early  life. 

Diagnosis. — The  nature  of  the  pelvis  may  sometimes  be  sus- 
pected upon  inspecting  the  body  of  an  undersized  woman,  but  the 
exact  condition  can  be  determined  only  by  exact  pelvimetry. 
Michaelis's  lozenge  is  narrower  than  in  the  normal  woman.  The 
various  measurements  are  proportionately  less  than  normal. 
Usually  the  promontory  is  accessible  and  the  linea  pectinata 
more  or  less  easily  palpable.  In  a  primipara,  palpation  of  this 
line  on  each  side  almost  certainly  indicates  transverse  contraction 


452 


ANOMALIES   OF  THE  BONY  PEL  VIS. 


of  the  pelvis.      In  normal  primiparae  it  cannot  be  outlined  per 
vaginam,  and  only  exceptionally  in  multiparae. 

In  advanced  pregnancy  it  may  be  associated  with  abnormal 
prominence  of  the  belly.  Malpresentations  and  malpositions, 
prolapse  of  the  cord,  etc.,  such  as  have  been  described  as  occur- 
ring with  contracted  pelves  in  general,  are  scarcely  more  frequent 
in  justo-minor  pelves  than  in  those  that  are  normal. 

Relation  to  Labor. — When  too  great  a  disproportion  does  not 
exist  between  the  fetal  head  and  the  pelvis,  delivery  may  take 
place,  but  is  much  prolonged.  Frequently  the  mother  may  be- 
come greatly  exhausted  and  the  pain  cease  for  a  time  during  the 
process.  As  the  head  descends  into  the  pelvis  there  is  apt  to  be 
much  greater  suffering  than  in  normal  cases,  and  there  is  an 
increased  risk  of  bruising  and  lacerating  the  maternal  soft  parts. 
The  mechanism  of  labor  in  such  cases  resembles  that  found  in 
normal  women,  except  that  flexion  is  more  marked.    The  shorter 

suboccipitobregmatic  plane  is  brought 
into  relation  with  the  brim  ;  as  a  result, 
very  early  in  the  second  stage  the 
upper  part  of  the  occiput  may  lie  in 
the  axis  of  the  pelvic  canal.  It  has 
been  already  pointed  out  that  in  the 
normal  mechanism  the  suboccipitobreg- 
matic plane  that  enters  into  relation  with 
the  brim  is  one  that  passes  through  the 
center  or  anterior  part  of  the  bregma. 
In  justo-minor  cases  the  plane  is  one 
that  passes  through  the  posterior  end. 
Internal  rotation,  extension,  and  exter- 
nal rotation  occur  as  in  normal  cases, 
but  take  place  much  more  slowly. 
Sometimes  delay  may  occur  after  partial  rotation.  The  shoulders 
also  are  apt  to  cause  delay. 

When  the  pelvis  is  too  small  to  allow  the  head  to  pass,  labor 
pains  continue  until  the  uterus  becomes  exhausted,  the  fetus  dies, 
and  the  mother's  life  may  become  endangered  unless  artificial 
delivery  is  carried  out. 

Moulding  of  the  Head. — The  appearance  of  the  head  after 
delivery  differs  markedly  from  that  presented  in  the  case  of 
normal  labor.  The  swelling  of  the  soft  tissues  forming  the  caput 
succedaneum  is  found  as  a  conical  projection  over  the  upper  part 
of  the  occiput.  The  skull  is  markedly  compressed  in  the  sub- 
occipitobregmatic diameter  and  elongated  in  the  occipitomental. 
In  profile  the  head  has  thus  the  appearance  of  an  ant  hill  or  an 
old-fashioned  sugar  loaf 

Management. — In  all  forms  of  justo-minor  pelvis  labor  must 
be  watched  with  the  greatest  care,  especially  if  during  the  last 


Fig.  167. — Extreme  flexion  of 
head  in  labor  in  a  justo-minor 
pelvis. 


DETAILED   STUDY  OF  INDIVIDUAL    PELVES.  453 

weeks  of  pregnancy  the  patient  has  complained  of  edema  of  the 
lower  extremities,  external  genitals,  or  lower  abdominal  wall, 
weakness  of  the  lower  extremities  or  marked  distress  in  the  pelvis 
and  abdomen,  or  if  there  has  been  any  impairment  of  the  function 
of  the  kidneys.  The  tendency  to  the  occurrence  of  eclampsia  in 
women  with  contracted  pelves  must  always  be  remembered. 

If  there  be  no  malposition  or  malpresentation  of  the  head,  and 
the  disproportion  between  the  latter  and  the  bony  canal  be  not 
marked,  labor  may  be  allowed  to  continue  normally.  When 
delay  occurs  either  at  the  brim  or  within  the  cavity  axis-traction 
forceps  should  be  employed,  the  patient  being  placed  in  Walcher's 
position.  In  this  way  a  head  of  normal  size  may  be  delivered 
through  a  brim  whose  conjugate  measures  3 J  inches. 

In  slight  degrees  of  obstruction  the  head  may  sometimes  be 
made  to  advance  by  Kristeller's  manipulation.  Occasionally  in 
thin  women,  when  the  head  is  above  .^- 

the  brim,  it  may  be  possible  to  adopt  v 

Hofmeier's  procedure  of  exercising 
pressure  on  the  head  through  the 
abdominal  wall,  a  towel  being  used 
to  protect  the  latter.  Version  should 
not  be  employed  in  a  justo-minor 
pelvis,  since  the  head  is  certain  to  be 
extended  when  it  reaches  the  brim, 
increasing  the  difficulty  of  delivery ; 
moreover,  pressure  on  the  cord  is 
likely  to  occur,  causing  asphyxiation. 

Symphysiotomy  is  recommended 
by  many  in  cases  in  which  the  con- 
jugata  vera  measures  3  to  3^^  in. 
Owing    to    the    great    reduction    of       ,  ^ig    168.— Extreme  moulding 

.^  .    ^^,  p  r^  ■  of  the  head  by  denvenng  through 

the    mortality   of    Caesarean    section     a  justo-minor  pelvis  (Barbour). 
during   recent  years,  this    operation 

is  to  be  recommended  when  the  fetus  is  alive  and  cannot  be 
safely  extracted  by  forceps,  both  when  the  difficulty  in  labor 
is  due  to  the  pelvic  contraction  and  also  when  the  head  is 
larger  than  normal.  When  the  fetus  is  dead,  embryulcia  is  the 
safest  method  to  deliver.  This  procedure  is  also  adopted  by 
many  authors  when  the  child  is  alive  and  cannot  be  delivered  by 
means  of  the  forceps,  though  undoubtedly  there  is  a  growing 
tendency  to  displace  this  destructive  operation  under  such  circum- 
stances by  symphysiotomy  or  Caesarean  section. 

2.  Uniformly  Enlarged  Pelves  {yEquibiliter  Justo-majoj^. — In 
very  large  women  the  pelvis  usually  shares  in  the  general  increase 
in  the  .size  of  the  body,  the  enlargement  being  characterized  by  a 
proportionate  increase  in  all  the  diameters  above  the  normal. 

During  the  last  months  of  pregnancy  the   uterus  usually  lies 


454 


ANOMALIES   OF   THE  BONY  PELVIS. 


at  a  lower  level  than  in  normal  cases,  the  fetal  head  being  found 
more  or  less  within  the  pelvic  cavity.  There  is  less  resistance  to 
the  passage  of  the  child  than  in  normal  pelves,  and  consequently 
in  some  cases  labor  may  be  precipitate.  Ahlfeld  has  noted  in  a 
number  of  cases  delay  of  the  head  in  the  pelvic  cavity,  the  sagittal 
suture  remaining  transverse. 

After  the  third  stage  there  is  a  greater  tendency  to  hemorrhage, 
especially  if  the  cervix  has  been  torn,  because,  as  I  have  demon- 
strated, the  normal  compression  of  the  extra-uterine  tissues  against 
the  upper  part  of  the  bony  pelvis  by  the  retracted  uterus  is  want- 
ing, a  freer  flow  of  blood  being  thereby  allowed  through  the  pelvic 
vessels. 

II.  Pelves  with  Abnormalities  of  Size,  Shape,  and  Inclination, 
or  Combinations  of  These. —  i.  Those  with  Minor  Developmental 
PecJiliarities. — {a)  Funnel-shaped  Pelvis. — Occasionally  a  female 
pelvis  may  present  an  abnormal  degree  of  contraction  of  the  bony 


if 

^ 

\ 

H#^ 

N 

i 

/ 

Fig.  169. — Funnel-shaped  pelvis  (Winckel). 

canal  toward  its  lower  portion,  the  shape  being  roughly  compared 
to  a  funnel.  The  alteration  is  mainly  due  to  the  altered  slope  of 
the  lateral  portion  of  the  wall,  though  the  sacrum  and  coccyx 
may  also  aid  in  its  formation. 

The  canal  may  somewhat  resemble  that  of  the  normal  male 
pelvis,  and  by  some  authors  male  and  funnel-shaped  are  used 
synonymously.  This  usage  is  not  accurate,  because  the  funnel- 
shaped  pelvis  may  be  female  in  every  other  characteristic.  It  is 
more  accurate  to  say  that  the  typical  funnel  pelvis  is  one  that 
retains  many  of  the  infantile  features.  The  sacrum  is  straighter 
and  more  elongated  than  in  the  normal  adult  pelvis.  The  de- 
formity is  very  rare. 

Relation  to  Labor. — When  the  head  enters  the  pelvis  its  ad- 
vance is  slow,  the   rate  of  progress  depending  upon  the  extent 


DETAILED   STUDY  OF  INDIVIDUAL    PELVES.  455 

of  pelvic  contraction  and  the  size  of  the  head.  Each  of  the 
movements  of  the  normal  mechanism  may  be  more  or  less  inter- 
fered with ;  the  maternal  soft  parts  are  apt  to  be  unduly  pressed 
against  the  bony  wall,  and  may  be  badly  bruised  or  lacerated. 
There  is  also  an  increased  risk  of  rupture  of  the  perineum  as  the 
head  passes  through  the  outlet. 

Management. — In  slight  degrees  of  contraction  labor  may 
take  place  spontaneously  and  satisfactorily.  When  there  is  delay, 
artificial  delivery  should  be  carried  out,  the  procedure  depending 
upon  the  conditions  present.  In  slight  cases  Kristeller's  manipu- 
lation may  sometimes  be  of  value,  but  the  forceps  is  usually  neces- 
sary. Forceps  should  never  be  used,  however,  if  sufficient  force 
must  be  employed  to  injure  the  wall  of  the  bony  canal  or  soft 
parts.  In  marked  cases  symphysiotomy,  embryulcia,  or  Caesarean 
section  may  be  carried  out.  The  latter,  however,  should  be  em- 
ployed only  if  the  case  be  diagnosed  during  pregnancy  or  before 
the  head  has  entered  the  brim  in  labor. 

{6)  Masculine  Pelvis. — In  rare  cases  a  woman's  pelvis  may  be 
masculine  in  type  and  may  possess  most  of  the  characteristics  of 
the  male  pelvis.  Owing  to  the  diminution  of  the  transverse  diam- 
eter of  the  brim,  the  head  is  very  apt  to  be  delayed  when  it  at- 
tempts to  enter  the  latter.  This  may  also  occur  when  the  head 
descends  toward  the  outlet  of  the  pelvis.  In  such  cases  the  axis- 
traction  forceps  proves  satisfactory  in  effecting  delivery  ;  but  when 
the  difficulty  is  extreme,  recourse  must  be  had  to  some  of  the 
other  methods  of  artificial  delivery. 

ic)  Shallow  Pelvis. — A  pelvis  is  said  to  be  shallow  when  the 
distance  between  the  inlet  and  outlet  is  relatively  less  than  that  in 
the  normal  pelvis.  The  condition  has  no  special  importance  in 
relation  to  labor,  though  it  probably  offers  less  resistance  to  the 
passage  of  the  head  than  does  the  normal  pelvis. 

{d)  Deep  Pelvis. — A  deep  pelvis  is  one  in  which  the  distance 
between  the  outlet  and  inlet  is  relatively  considerably  greater  than 
in  the  normal  pelvis.  The  condition  may  increase  the  difficulty 
of  labor  owing  to  the  greater  length  of  bony  canal  to  be  tra- 
versed by  the  fetus.  When  labor  is  delayed,  the  axis-traction 
forceps  should  be  tried. 

2.  Pelves  Contracted  in  an  Anteroposterior  Diameter. — Flat 
Pelvis. — The  term  flat  has  long  been  applied  to  pelves  whose 
anteroposterior  bony  measurement  is  relatively  less  than  that  of 
the  normal  pelvis. 

{a)  The  Non-rachitic  or  Simple  Flat  Pelvis. — In  this  variety 
of  deformity  the  bones  may  present  all  the  ordinary  female  char- 
acteristics, there  being  no  evidence  of  previous  rickets.  The  con- 
jugata  vera  is  usually  larger  than  3  in.,  though  it  is  considerably 
below  the  normal.  The  transverse  diameter  of  the  pelvis  is  rela- 
tively increased.      The  sacrum  is   usually  smaller  than  normal. 


456 


ANOMALIES   OF  THE  BONY  PEL  VIS. 


Sometimes  the  whole  pelvis  is  smaller  than  normal   as  well  as 
flattened.     In  some  cases  there  is  a  double  promontory. 

Etiology.— Th^    etiology    of  this    formation    is    not   definitely 
known.     It  is  mostly  found  in  women  who  have  been  sick  or 


Naegele  Malacosteon 

Fig.  170. — Various  forms  of  pelves,  showing  the  shape  of  the  inlet  or  brim  (Bumm). 

poorly  nourished  in  early  life,  especially  if  they  have  engaged  in 
hard  work  or  excessive  walking  or  lifting,  the  deformity  being 
easily  explained  by  the  approximation  of  the  sacrum  and  pubes 


DETAILED   STUDY  OF  INDIVIDUAL   PELVES. 


4S7 


as  a  result  of  weakening  in  the  bony  structure.  It  may  be  found 
both  in  large  and  small  women. 

Diagnosis. — Ordinarily  there  is  nothing  whatever  in  the  woman's 
external  appearance  to  suggest  the  deformity,  all  outward  signs 
of  rickets  being  absent.  In  carrying  out  careful  pelvimetry,  short- 
ening of  the  external  and  diagonal  conjugates  and  the  altered 
relationships  between  the  interspinous  and  intercristal  diameters 
may  be  determined ;  in  slight  degrees  of  deformity  the  latter  may 
be  little  changed  from  the  normal.  Some  shortening  in  the  ver- 
tical diameter  of  Michaelis's  lozenge  may  be  detected. 

{b)  Rickety  Flat  Pelvis. — This  deformity  is  a  very  important 
one  and  must  be  described  in  detail.  The  bones  of  the  pelvis  in 
general  differ  somewhat  from  those  of  the  normal  pelvis,  being 


Fig.  171. — Flat  non-rachitic  pelvis  (Kleinwachter). 

thicker,  coarser,  and  less  expanded  than  those  of  the  latter. 
These  alterations  are  due  to  the  disturbances  in  ossification  caused 
by  the  disease.  The  crests  of  the  ilium  are  less  sinuous  than  nor- 
mal and  tend  to  be  directed  more  outward  than  in  normal  cases, 
great  variations  being  found.  Thus,  while  in  normal  pelves  the 
intercristal  is  on  the  average  an  inch  wider  than  the  interspinous, 
in  the  rickety  pelvis  the  interspinous  diameter  approaches,  equals, 
or  exceeds  the  intercristal  measurement.  The  altered  curve  of 
the  iliac  crest  is  partly  due  to  defective  development,  the  normal 
curve  being  determined  after  the  period  during  which  rickets  is 
common.  The  iliac  wings  are  less  expanded  than  in  normal 
cases,  flattening  in  the  bones  being  considerably  due  to  the  drag- 
ging of  the  sacro-iliac  ligaments  and  to  the  influence  of  the  glutei 


458 


ANOMALIES   OF  THE  BONY  PELVIS. 


and  sartorii  muscles.  The  iliac  fossae  look  more  directly  forward  ; 
the  iliac  wings  in  general  have  a  more  dwarfed  appearance  than  in 
the  normal  pelvis. 

The  pelvic  inlet  differs  from  that  of  the  normal  pelvis  in  being 
somewhat  kidney-shaped,  the  anteroposterior  diameter  being  less 
than  the  normal  conjugate,  the  transverse  diameter  being  both 
relatively  and  absolutely  increased.  The  cavity  of  the  pelvis  is 
roomier  in  its  lowest  portion  than  in  the  normal  pelvis,  owing  to 
the  separation  of  the  lateral  bony  walls.  The  anterior  surface  of 
the  sacrum  is  somewhat  flattened  from  side  to  side,  and  may  even 


Fig.  172. — Pregnant  rachitic  dwarf.     Weight  45  pounds.     Fifty-four  fractures  of  bones 
had  occurred  (W.  G.  Willard). 

be  convex,  owing  to  the  bulging  of  the  bodies  of  its  component 
vertebrae.  The  outlet  may  not  be  very  much  altered  from  the 
normal  in  its  anteroposterior  diameter,  though  this  may  be  some- 
what increased.  The  transverse  is  decidedly  enlarged,  owing  to 
the  separation  of  the  ischial  tuberosities.  The  subpubic  angle  is 
larger  than  normal,  and  the  acetabula  are  directed  more  forward 
in  the  erect  position  of  the  body. 

On  vertical   mesial  section  the  sacrum  is   less  concave  from 
above  downward  than  in  the  normal  pelvis.     Its  lower  end  with 


DETAILED   STUDY  OF  INDIVIDUAL   PELVES.  459 

the  coccyx  is  frequently  bent  forward  at  a  sharp  angle  at  the  level 
of  the  fourth  vertebra.  The  vertical  axis  of  the  upper  part  of  the 
sacrum  is  not  parallel  with  that  of  the  symphysis,  as  in  the  normal 
pelvis,  but  converges  toward  it  if  prolonged  above  the  brim.  The 
vertical  measurement  of  the  symphysis  is  greater  than  in  normal 
cases.  Owing  to  the  greater  height  of  the  pubes,  as  well  as  to 
the  divergence  forward  of  the  lower  end  of  this  bone,  the  diagonal 
conjugate  exceeds  the  conjugata  vera  by  an  amount  that  is  rela- 
tively greater  than  in  the  case  of  the  normal  pelvis.  In  the  latter 
the  average  difference  between  these  diameters  is  \  in. ;  in  a  well- 
marked  rickety  pelvis  it  is  f  in.  or  more.  Sometimes  osteophytic 
growths  may  be  present  in  rachitic  pelves. 

Explanation  of  the  Changes  in  the  Rickety  Pelvis. — The  main 


Fig.  173.— Effect  of  lessened  slant  outward  of  symphysis  in  a  rachitic  pelvis  upon  rela- 
tionship between  the  true  and  the  conjugate  diameter  (Ribemont-Dessaignes). 

features  of  the  rickety  pelvis  are  explained  by  the  following 
factors  :  During  the  active  stage  of  the  disease  the  bones  are 
softer  than  normal,  and  changes  are  produced  because  of  their 
unfitness  to  sustain  the  weight  of  the  body.  The  weight  of  the 
latter,  transmitted  through  the  attachment  of  the  sacral  and  iliac 
bones,  tends  to  cause  the  promontory  to  sink  toward  the  pubes, 
bringing  about  a  rotation  of  the  sacrum  on  a  transverse  axis 
passing  through  the  sacro-iliac  joints.  The  lower  end  of  the 
sacrum  with  the  coccyx  tends  to  move  upward,  but  is  restrained 
by  the  strong  ligaments  attached  to  it,  and  there  results  usually  a 
sharp  bend  at  the  lower  end  of  the  sacrum. 

The  action  of  various  muscles  attached  to  the  pelvis  may  also 
assist  in  altering  its  shape  ;  thus,  the  adductor  and  rotator  muscles 


460 


ANOMALIES   OF   THE  BONY  PEL  VIS. 


of  the  thigh  are  beheved  to  play  a  part  in  separating  the  tuberos- 
ities of  the  ischii,  though  the  latter  change  is  also  brought  about 
as  a  result  of  sitting.  Alterations  in  the  shape  of  bones  in  the 
condition  of  intra-uterine  fetal  rickets  are  believed  to  be  mainly 
due  to  the  action  of  muscles  attached  to  them.  In  the  great 
majority  of  cases,  however,  rickets  is  an  affection  of  early  child- 
hood, and  the  changes  produced  by  it  vary  greatly  and  depend 
upon  a  number  of  factors,  such  as  the  age  and  habits  of  the  child^ 
the  intensity  of  the  affection,  etc. 

Varieties    of  Rachitic  Pelvis. — In    some    cases   the  pelvis,   as 


Flo.  174. — View  of  pelvis  from  be- 
hind in  a  rachitic  woman.  Michaelis's 
lozenge  is  almost  a  triangle  (Bumm). 


Fig.  175. — Posterior  aspect  of 
a  woman  with  a  transverse  con- 
tracted pelvis.  Michaelis's  lozenge 
is  narrowed  (Bumm). 


well  as  being  rachitic,  is  smaller  than  normal,  its  development 
having  been  markedly  interfered  with,  this  form  being  known  as 
the  rachitic  generally  contracted  pelvis.  In  other  cases  evidences 
of  rickets  may  be  associated  with  features  that  are  peculiarly  in- 
fantile. Occasionally  the  pubes  is  somewhat  indented  toward  the 
promontory,  giving  to  the  brim  a  somewhat  figure-of-8  shape. 

When  rickets  is  associated  with  marked  lateral  curvature  of 
the  spine,  the  pelvis  is  known  as  the  scoliorachitic  obliquely  con- 
tracted form.  Rarely  there  is  indentation  of  the  pelvis  at  both 
acetabula,  giving  rise  to  the  variety  known  as  rachitic  rostrate  or 


DETAILED   STUDY  OF  INDIVIDUAL   PELVES. 


461 


pseudomalacosteon  ;  the  pubes  projects  forward  in  a  kind  of  beak, 
as  in  the  malacosteon  pelvis,  the  inlet  having  a  somewhat  triradiate 
shape  Hke  that  of  the  latter. 

Diagnosis. — In  diagnosing  the  rachitic  pelvis  it  is  necessary  to 
obtain  the  previous  history  of  the  woman's  health,  to  examine  her 
frame,  and  to  measure  the  pelvis.  Frequently  a  history  may  be 
obtained  of  rickets  in  childhood ;  she  may  be  stunted  in  growth, 
may  present  a  square   head,  pigeon-breast,   curved   long  bones 


Fig.  176. — Flat  rachitic  pelvis  :  a,  viewed  from  above  ;  b,  viewed  from  below. 


with  thickened  ends,  etc.  When  she  lies  on  a  flat  surface  there 
may  be  well-marked  lumbar  lordosis.  The  vertical  diameter  of 
the  lozenge  of  Michaelis  is  shortened,  owing  to  sinking  of  the 
promontory  and  the  lumbar  vertebrae.  In  extreme  degrees  of 
deformity  the  upper  angle  of  the  lozenge  (spine  of  last  lumbar 
vertebra)  may  be  almost  in  the  line  that  joins  the  lateral  angles, 
the  lozenge  consequently  approximating  to  a  triangle  in  outline. 
On  measuring  the  pelvis  with  the  pelvimeter  changes  in  the 


462 


ANOMALIES   OF  THE  BONY  PELVIS. 


relationships  of  the  interspinous  and  intercristal  diameters  may  be 
found.  The  external  and  diagonal  conjugates  are  lessened,  the 
difference  between  the  diagonal  and  true  conjugates  being  greater 


Fig.  177. — Rachitic  deformity  in  pelvis  of  a  child. 

than  in  the  normal  pelvis.     The  ischial  tuberosities  are  found  to 
be  wider  than  normal  and  the  subpubic  angle  greater. 

Sometimes,  owing  to  the  projection   of  the  joints  of  the  first 


Fig.  178. — Overlapping  of  cranial  bones  in  a  futile  attempt  to  engage  in  superior  strait 
of  a  rachitic  pelvis  (Smellie). 

and  second  sacral  vertebrae,  a  prominence  may  be  formed  that 
may  easily  be  mistaken  for  the  true  promontory,  and  indeed  for 
obstetric  purposes  it  may  sometimes  take  the  place   of  the  true 


DETAILED   STUDY  OE  INDIVIDUAL    PELVES.  465 

promontory.  In  measuring  such  a  pelvis  the  available  brim  con- 
jugate should  be  measured  from  the  projection  that  is  nearer  the 
pubes.  When  marked  lordosis  is  present,  a  point  on  the  lower 
lumbar  vertebra  may  be  nearer  the  symphysis  than  the  actual 
promontory. 

Relation  to  Pregnancy. — This  has  already  been  detailed. 

Relation  to  Labor. — When  the  pelvis  is  not  too  much  con- 
tracted to  prevent  the  passage  of  the  fetus,  the  mechanism  of  labor 
usually  takes  place  as  follows  :  At  the  beginning  the  long  diameter 
of  the  head  usually  lies  in  the  transverse  of  the  brim,  not  in  the 
oblique,  as  is  common  in  normal  vertex  cases.  The  sinciput 
tends  to  lie  at  a  lower  level — /.  e.,  the  head  is  somewhat  extended  ; 
the  sagittal  suture  is  usually  nearer  the  posterior  wall  of  the 
pelvis — the  so-called  "  anterior  parietal-bone  presentation."     Very 


Fig.  179. — Spoon-shaped  depression  on  head  after  spontaneous  delivery  in  a  flat  pelvis 

(Bumm). 

rarely  the  sagittal  suture  is  nearer  the  pubes — the  so-called  "  pos- 
terior parietal-bone  presentation."  In  other  words,  the  head 
possesses  the  Naegele  obliquity  well  marked.  These  relationships 
of  the  head  are  well  established  at  the  beginning  of  the  second 
stage  of  labor. 

Considerable  variations  are  found  in  the  descriptions  of  the 
head  movements  as  given  by  different  authorities.  The  follow- 
ing are  probably  most  frequently  observed :  In  cases  of  an- 
terior parietal  presentation,  as  descent  proceeds,  the  characteristic 
change  is  extension  of  the  head  or  dipping  of  the  sinciput  (the 
Michaelis  obliquity),  the  occiput  remaining  at  the  side  of  the 
pelvis  in  relation  to  the  lower  part  of  the  iliac  fossa,  the  whole 
head   being   pushed   toward    that    side,   the    shortest    transverse 


464 


ANOMALIES   OF   THE   BONY  PELVIS. 


diameter  of  the  head,  the  bitemporal,  entering  into  relation  with 
the  shortest  diameter  of  the  brim,  the  anteroposterior  or  con- 
jugate. Along  with  this  process  of  extension  there  is  a  movement 
of  the  head  known  as  the  rounding  of  the  promontory.  This 
consists  in  the  rotation  of  the  head  on  the  anteroposterior  axis,  so 


Fig.  180. — Diagram  illustrating  one  method  by  which  the  head  rounds  the  prom- 
ontory in  a  flat  pelvis  when  at  the  beginning  of  labor  the  sagittal  suture  lies  nearest 
the  pubes :  i,  First  position  of  the  head ;  2,  second  position  of  the  head. 

that  the  sagittal  suture,  from  being  directed  toward  the  back  of 
the  pelvis,  is  moved  first  toward  the  middle  of  the  pelvis  and 
afterward  again  to  the  back,  though  when  the  latter  position  is 
reached  the  head  is  at  a  lower  level,  having  rounded  the  prom- 
ontory. 


Fig.  181. — Diagram  illustrating  the  usual  method  by  which  the  head  rounds  the 
promontory  in  a  flat  pelvis  when  at  the  beginning  of  labor  the  sagittal  suture  lies 
nearest  the  promontory  :  i,  First  position  of  the  head ;  2,  second  position  of  the  head ; 
3,  third  position  of  the  head. 

After  the  passage  of  the  inlet  there  is  usually  little  trouble. 
The  occiput  may  rotate  to  the  front  and  the  rest  of  the  labor  go 
on  as  in  the  normal  pelvis,  the  occiput  turning  to  the  front,  the 


DETAILED   STUDY   OF  INDIVIDUAL    PELVES.  465 

other  movements  following.  Sometimes  when  the  labor  pains 
are  strong  the  head  may  be  pushed  through  the  outlet  with  little 
or  no  attempt  at  mechanism.  Occasionally  there  may  be  delay 
when  the  head  is  within  the  pelvic  cavity. 

In  some  cases  early  marked  extension  of  the  head  may  bring 
about  a  brow  or  face  presentation,  the  labor  being  thereby  in- 
creasingly comphcated.  In  cases  of  posterior  parietal  presentation 
the  sinciput  dips,  the  side  of  the  head  above  the  brow  descends, 
rounding  the  promontory,  and  the  head  as  a  whole  becomes 
pushed  to  the  side  of  the  pelvis  in  relation  to  which  the  occiput 
lies.  When  labor  is  delayed  the  head  may  be  found  in  any  of  the 
relationships  that  occur  in  connection  with  these  various  mechan- 
isms. In  pelves  that  are  very  small,  such  as  the  generally  con- 
tracted rachitic,  the  head  may  attempt  to  pass  the  brim  as  if  the 
case  were  a  pure  justominor — viz.,  in  a  markedly  flexed  attitude. 


Fig.  182. — Diagram  illustrating  one  method  by  which  the  head  rounds  the  prom- 
ontory in  a  flat  pelvis  when  at  the  beginning  of  labor  the  sagittal  suture  lies  nearest  the 
promontory :  i,  First  position  of  the  head  ;   2,  second  position  of  the  head. 

the  type  of  mechanism  being  undoubtedly  dependent  upon  the 
predominant  feature  of  the  deformity. 

It  is  in  connection  with  labor  in  rachitic  pelves  that  those  com- 
plications are  apt  to  arise  that  have  been  described  on  page  440 — 
i.e.,  pouching  of  the  bag  of  membranes,  premature  rupture  of  the 
membranes,  prolapse  of  the  cord,  malpresentations  and  malposi- 
tions, etc.  Localized  pressure  of  the  maternal  soft  parts  against 
the  promontory  or  pubes  may  result  in  their  necrosis. 

Moulding  of  the  Head. — The  characteristic  marking  on  the  fetal 
head  is  a  groove  or  series  of  depressions  in  the  skull,  caused  by  the 
promontory.  These  vary  in  situation  in  different  cases.  They 
are  usually  in  the  anterior  parietal  region  or  lateral  frontal  region, 
and  sometimes  may  be  found  on  the  cheek.  The  posterior  parietal 
bone  is  usually  depressed  below  the  anterior.  The  posterior 
region  of  the  skull  may  be  somewhat  flattened. 

.30 


466 


ANOMALIES   OF  THE  BONY  PELVIS. 


■  Pelvic  Presentations  in  Flat  Pelves. — Unless  the  pelvic  deformity 
be  very  marked,  there  is  usually  no  interference  with  the  passage 
of  the  body  of  the  fetus  through  the  brim  ;  the  arms,  however, 
are  very  apt  to  be  displaced  upward,  and  the  head  is  frequently 
extended,  whether  the  arms  are  displaced  or  not.  In  slight  con- 
traction of  the  brim  the  head  usually  passes  in  a  flexed  attitude. 
The  more  marked  the  contraction,  the  more  apt  the  head  is  to 
extend  upward ;  this  is  apt  to  be  a  serious  cause  of  delayed  labor. 
Treatmejit. — In  cases  of  slight  deformity  labor  may  take  place 
spontaneously  without  being  much  longer  than  the  average  nor- 
mal case.  Very  close  attention  should  be  given  to  it  through- 
out, frequent  examinations  being  made  to  determine  the  progress 
of  the  head,  its  changed  relationships  to  the  brim,  and  to  detect 


Fig.  183. — Marks  made  by  promontory  on  child's  head  and  face  (Dickinson). 

abnormalities,  such  as  prolapse  of  the  cord,  inefficiency  of  the  bag 
of  membranes,  and  development  of  malpresentations  and  malposi- 
tions, etc.  When  delay  tends  to  occur  at  the  brim  in  minor  cases 
it  is  advisable  to  place  the  patient  in  the  Walcher  position  as  much 
as  possible,  in  order  to  gain  a  little  more  room  at  the  inlet  by  the 
increase  in  length  of  the  conjugata  vera.  When  this  is  ineffective 
or  when  the  contraction  is  quite  marked,  artificial  interference  is 
necessary  before  the  woman  has  remained  too  long  in  labor. 

Engagement  of  the  head  may  sometimes  be  brought  about  by 
the  Kristeller  manipulation  or  by  Hofmeier's  procedure  of  pushing 
the  head  downward  through  the  abdominal  wall.  In  trying  these 
methods  the  patient  should  be  placed  in  Walcher's  position. 


DETAILED  STUDY  OF  INDIVIDUAL   PELVES. 


467 


For  many  years  most  authorities  have  recommended  that  the 
fetus  be  delivered  by  version — i.  e.,  podalic  version.  Since  the 
axis-traction  forceps  has  come  into  use  it  has  been  satisfactorily 
employed  by  several  obstetricians  in  a  number  of  these  cases. 
This  method  of  treatment  is  largely  due  to  the  advocacy  of  Milne 
Murray,  of  Edinburgh,  who  holds  that  the  employment  of  axis- 
traction  forceps  is  as  favorable  to  the  child  as  version,  and  no 
more  dangerous  to  the  mother.  For  many  years  an  important 
objection  to  the  use  of  forceps  was  the  statement  that  the  antero- 
posterior grasp  of  the  head  usually  obtained  in  these  cases  not 
only  tended  to  injure  the  fetal  parts,  but  to  produce  a  telescoping 
of  the  cranial  bones,  whereby  increased  bulging  of  the  head  took 


Fig.  184. — Pressure  of  promontory  upon  head  in  a  contracted  pelvis  (Smellie). 

place  in  the  transverse  diameter,  thereby  increasing  the  narrow 
bitemporal  diameter  that  should  pass  through  the  brim  in  rela- 
tion to  the  narrow  conjugate.  Milne  Murray  showed  experi- 
mentally that  this  compensatory  transverse  bulging  does  not 
ordinarily  occur,  but  that  it  takes  place  in  a  vertical  direction  on 
the  head,  a  change  that  cannot  materially  delay  the  passage  of 
the  head  through  the  pelvic  brim.  Recently  he  has  advised  a 
slight  modification  of  the  ordinary  axis-traction  forceps,  by  which 
it  is  possible  to  exercise  traction  with  greater  efficiency,  the  axis  of 
the  pelvis  being  followed  more  nearly  than  is  possible  by  the 
ordinary  instrument. 

It  cannot  be  too  strongly  emphasized  that  only  axis-traction  for- 


468 


ANOMALIES    OF   THE   BONY  PELVIS. 


ceps  should  be  employed  in  instrumental  delivery  in  these  cases. 
The  ordinary  long  forceps  must  never  be  used,  because  in  carry- 
ing out  traction  with  it  the  head  is  compressed  and  is  very  apt  to 
be  injured.  Moreover,  much  of  the  force  applied  is  lost.  (See 
chapter  on  Forceps.)  Murray  has  reported  one  case  where  he  ex- 
tracted the  head  successfully  with  axis-traction  forceps,  in  which 
the  conjugata  of  the  brim  measured  2.57  in.      The  author  has 


Fig.  185. — Walcher  position. 

brought  about  safe  delivery  a  number  of  times  in  pelves  whose  con- 
jugates varied  from  3^  to  3^  in.  When  the  forceps  is  used  in  such 
cases,  the  patient  should  always  be  placed  in  Walcher's  position,  in 
order  that  the  greatest  amount  of  room  may  be  gained  at  the 
inlet ;  though  the  increase  may  be  slight  in  most  cases,  it  may 
make  all  the  difference  between  failure  and  success.  The  head 
should  be  steadied  by  the  hands  of  an  assistant,  applied  to  the 
abdominal  wall. 

It  is  the  custom  of  many,  when  the  head  has  passed  through 
the  brim,  to  elevate  the  limbs  of  the  mother,  flexing  them  on  the 


DETAILED   STUDY  OF  INDIVIDUAL    PELVES. 


469 


abdomen,  in  order  to  obtain  an  increase  in  the  conjugate  of  the 
outlet.  This  procedure  is  unnecessary,  because  there  is  usually 
abundant  room  in  the  transverse  diameter  of  the  outlet,  and  the 
gain  in  the  anteroposterior  is  only  theoretic  and  not  worthy  of 
consideration.  It  is  best  to  continue  the  delivery  with  the  limbs 
of  the  woman  extended  or  in  Walcher's  position,  in  order  to 
obtain  the  greatest  degree  of  relaxation  of  the  soft  parts  and 
thereby  diminish  the  risk  of  lacerating  the  perineum. 

Summing  up  the  relative  merits  and  demerits  of  version  and 
forceps  delivery,  it  may  be  stated  against  version  that  the  pro- 
cedure is  always  risky  or  impossible  after  the  membranes  have 
been  ruptured  for  a  time  and  the  uterus  retracted  on  the  fetus ; 
that  complications  are  apt  to  arise  by  extension  upward  of  the 
head  or  upper  extremities,  or  from  injury  to  the  neck  or  limbs  of 
the  fetus ;  that  the  fetus  may  become  asphyxiated  by  interference 
with  the  cord  circulation.  Version  should  be  the  operation  of 
election  when  the  arm,  leg,  or  cord  is  prolapsed  and  cannot  be 


Fig.  186. — Asymmetry  of  head  often  found  after  delivery  through  a  flat  pelvis.  The 
head  is  viewed  from  behind ;  one  parietal  bone  (that  which  was  anterior  in  the  pelvis) 
is  more  curved  and  prominent  than  the  other  (Tarnier  and  Budin). 

replaced ;  when  the  head  rests  on  the  linea  pectinata,  or  when  the 
Naegele  obliquity  is  extremely  marked,  providing  rupture  of  the 
uterus  does  not  threaten. 

When  forceps  is  used,  the  various  risks  associated  with  breech 
deliveries  are  absent ;  delivery  may  be  affected  long  after  dilata- 
tion of  the  cervix  and  rupture  of  the  membranes  ;  the  fetus  may 
be  extracted  as  nearly  as  possible  in  the  proper  axis  of  the  pelvis 
without  unnecessary  waste  of  power ;  the  anteroposterior  grip  of 
the  head  is  not  necessarily  injurious  to  the  fetus  nor  liable  to 
cause  such  an  amount  of  transverse  bulging  as  will  increase  the 
difficulty  of  the  passage  of  the  head.  It  must  be  distinctly  un- 
derstood that  the  forceps  is  not  to  be  used  to  overcome  bony 
resistance.  When  careful  traction  fails  to  move  the  head  after  a 
fair  trial,  the  instrument  should  be  removed. 

In  cases  in  which  these  methods  are  considered  inadvisable. 


470 


ANOMALIES   OF  THE  BONY  PELVIS. 


various   other  procedures   are  recommended — e.  g.,  embryulcia, 
Caesarean  section,  symphysiotomy,  and  premature  labor. 

In  some  countries  symphysiotomy  has  been  popular  with  or 
without  the  combined  use  of  forceps,  care  being  taken  that  the 
pelvic  contraction  is  not  too  excessive.  This  operation  is  likely 
to  displace  premature  labor,  for  the  living  child  delivered  at  full 
time  by  means  of  symphysiotomy,  assisted  if  necessary  by  the 
axis-traction  forceps,  is  better  than  a  premature  delivery  with  the 
risks  of  obtaining  a  dead  child,  a  weak   one,  or  one  difficult  to 


rear. 


As  regards  embryulcia,  the  tendency  is  now  growing  to  em- 
ploy it  only  when  the  fetus  is  dead  or  when  circumstances  do  not 
permit  the  adoption  of  a  conservative  surgical  procedure. 


Fig.  187. — Asymmetry  of  head  sometimes  found  after  delivery  through  a  flat  pelvis. 
The  head  is  viewed  from  above.  In  addition  to  the  changes  shown  in  Fig.  186,  the  right 
and  left  halves  are  asymmetrically  disposed  (Tarnier  and  Budin). 

A  further  consideration  of  the  relative  values  of  these  methods 
of  treatment  will  be  given  when  the  latter  are  considered  in  detail. 

Spondylolisthesis. — This  deformit}'  is  a  very  rare  one.  It  con- 
sists of  bulging  of  the  lower  lumbar  vertebrse  downward  into  the 
true  pelvis,  the  sacrum  being  also  pushed  downward  and  back- 
ward, and  the  anterior  part  of  the  pelvis  being  somewhat  elevated. 
The  anteroposterior  diameter  of  the  upper  part  of  the  pelvis  is 
diminished,  variations  occurring  according  to  the  amount  of  dislo- 
cation of  the  vertebrae.  The  outlet  of  the  pelvis  is  contracted  in 
its  measurements. 


DETAILED  STUDY  OF  INDIVIDUAL   PELVES. 


471 


Etiology. — The  explanation  of  this  deformity  is  not  certain  in 
all  cases.  It  has  been  attributed  to  disease  or  faulty  development 
or  ossification  in  the  bones.  These  may  be  predisposing  condi- 
tions in  some  cases,  but  it  is  certain  that  the  change  may  be 
brought  about  in  healthy  women  following  falls  or  the  cariying 
of  heavy  weights.  Lane  has  shown  that  stretching  of  the  liga- 
ments, atrophy,  and  severance  of  bones  may  take  place. 

Physical  Signs. — The  woman  is  somewhat  stunted,  the  abdo- 
men tending  to  be  somewhat  pendulous.  The  ribs  are  close  to 
the  iliac  bones,  and  the  flanks  are  prominent.  The  outlines  of  the 
iliac  crests  are  very  prominent  when  the  woman  is  viewed  from 
behind ;  the  posterior  processes  of  the  upper  sacral  vertebrae  are 
usually  easily  distinguished  beneath  the  skin,  a  deep  depression 


Fig.  iE 


-Ahlfeld's  case  of  spondylolisthesis. 


being  seen  over  the  base  of  the  sacrum.  The  distance  between 
the  posterior  iliac  spines  is  greater  than  normal.  The  pubes  is 
higher  than  in  normal  cases,  the  vulvar  region  being  further  for- 
ward. The  inclination  of  the  brim  is  greatly  diminished,  and  the 
external  conjugate  of  Baudelocque  is  less  than  normal.  On 
vaginal  examination  the  characteristic  contractions  already  de- 
scribed may  be  easily  distinguished.  The  lumbar  vertebrae  are 
readily  palpated,  and  with  them  the  lower  end  of  the  aorta  with 
its  iliac  divisions  may  be  felt. 

In  determining  the  available  conjugate  of  the  brim,  measure- 
ment is  made  from  the  symphysis  to  the  nearest  portion  of  the 
lumbar  projection.  There  is  no  fixed  relationship  between  the 
diagonal  and  true  conjugates,  owing  to  the  variations  that  are 


472 


ANOMALIES    OF   THE   BONY  PELVIS. 


found  in  the  extent  of  deformity  and  the  inchnation  of  the  pelvis. 
When  the  woman  walks  she  carries  her  shoulders  well  back,  and 
her  feet  are  usually  inclined  directly  forward,  the  toes  not  turning 
out.  In  some  cases  a  grating  feeling  (crepitus)  is  noted  in  the 
region  of  the  hips  during  locomotion. 

Influence  on  Pregnancy. — The  most  characteristic  disturbances 
of  pregnancy  may  be  found  with  spondylolisthesis.     Owing  to  the 

vertical  shortening  of  the 
abdomen,  the  uterus  finds 
scanty  room  for  its  upward 
development,  and  in  the  ad- 
vanced months  is  deflected 
markedly  forward,  though  it 
may  be  displaced  in  other 
directions  ;  malpresentations 
and  malpositions  of  the  fetus 
occur  as  a  result. 

Influence  on  Labor. — The 
pelvic  deformity  may  be  com- 
pared to  that  found  in  rick- 
ets as  regards  the  general 
alteration  presented  at  the 
brim,  the  characteristic 
change  being  flattening.  In 
cases  in  which  the  contrac- 
tion is  not  too  great  to 
prevent  the  passage  of  the 
fetus,  the  latter  passes 
through  the  pelvis  by  a 
mechanism  similar  to  that 
found  in  rickety  womeir  In 
addition  to  the  delay  at  the 
brim  there  may  be  delay  at 
the  outlet,  owing  to  its  con- 
tracted condition.  In  a  considerable  percentage  of  the  cases  of 
deformity  the  fetus  cannot  be  delivered  by  the  natural  passage 
unless  embryulcia  or  Caesarean  section  be  carried  out. 

TrcatJnent. — Cases  of  labor  are  conducted  on  lines  similar  to 
those  observed  in  rachitic  women.  Delay  or  difficulty  may  neces- 
sitate version,  force,  Csesarean  section,  or  embryulcia,  according 
to  the  degree  of  the  deformity. 

3.  Pelves  Contracted  in  an  Oblique  Diameter. — {ci)  As  a  Result 
of  Loss  of  One  Leg  or  Impaired  Use  of  One  Leg  in  Early  Life. — 
When  the  use  of  one  limb  is  abolished  or  impaired  during  early 
life,  owing  to  disease  or  injury  of  bones  or  joints,  so  that  the 
weight  of  the  body  is  transmitted  for  some  time  entirely  through 
the  sound  extremity,  that  part  of  the  pelvic  wall  in  relation  to  the 


Fig.  189. 


-Spondylolisthesis,  well    marked 
(Schauta). 


DETAILED   STUDY  OF  INDIVIDUAL    PELVES. 


473 


sound  thigh  tends  to  be  approximated  to  the  promontory,  pro- 
ducing an  obhque  contraction  in  the  pelvic  cavity,  varying  in 
degree  in  different  cases.  Along  with  the  contraction  there  is 
usually  some  compensatory  bulging  outward  of  the  pelvic  wall 
on  the  side  of  the  inactive  limb. 

{b)  As  a  Rcsjilt  of  Imperfect  Development  of  One  Side  of  the 
Pelvis  {Naegele  Pelvis). — When  an  ala  of  the  sacrum  is  partly  or 


Fig.  190.— Pelvis  obliquely  contracted  by  congenital  dislocation  of  one  femur  :  a,  Viewed 
from  above  ;  b,  vievv^ed  from  below. 

entirely  deficient,  an  oblique  contraction  of  the  pelvis  is  produced, 
the  OS  innominatum  on  the  affected  side  lying  nearer  the  vertebral 
column  than  that  of  the  healthy  side.  The  sacrum  is  narrowed 
and  is  slightly  rotated,  so  that  its  anterior  surface  is  turned  some- 
what toward  the  diseased  .side.  The  os  innominatum,  as  well  as 
being  moved  nearer  the  middle  line  of  the  spine,  is  tilted  a  little 


474 


ANOMALIES   OF   THE   BONY  PELVIS. 


upward  and  backward,  its  ischial  tuberosity  lying  at  a  little  higher 
level  than  that  of  the  healthy  side,  its  ischial  spine  projecting  more 
distinctly  into  the  pelvic  cavity.  Its  iliopectineal  line  is  often  less 
curved  than  normal,  and  its  acetabulum  is  directed  more  laterally. 
The  subpubic  angle  is  not  symmetric,  being  directed  more  to- 
ward the  affected  side  of  the  pelvis.  The  shape  of  the  brim  is 
characteristic,  though  it  varies  according  to  the  deformity  of  the 
sacrum.  It  has  a  somewhat  ovoid  shape,  the  small  end  of  the 
ovoid  being  at  the  sacro-iliac  joint  on  the  affected  side.  The  pelvic 
diameter,  which  is  shortened,  is  that  denominated  by  the  healthy 
sacro-iliac  joint — z.  e.,  if  the  sacrum  is  affected  on  the  right  side, 
the  shortened  oblique  diameter  of  the  brim  is  the  left.  There  is 
usually  ankylosis   of  the  sacro-iliac   joint   on  the  diseased   side. 


Fig.  191. — Singly  obliquely  contracted  or  Naegele  pelvis  (Winckel). 


Michaelis's  lozenge  is  usually  asymmetric,  the  lateral  angle  being 
higher  on  one  side  than  on  the  other,  and  the  transverse  diameter 
slightly  diminished. 

Etiology. — It  is  not  possible  to  decide  in  any  given  case  as  to 
the  cause  that  has  led  to  the  defect  in  the  wing  of  the  sacrum.  In 
some  cases  it  may  be  congenital,  the  normal  bone  development 
having  been  interfered  with,  or  there  may  have  been  some  diseased 
condition  in  early  years.  The  ankylosis  of  the  joint,  which  usually 
though  not  always  takes  place,  is  secondar}^  to  the  changes  in  the 
sacrum.  The  displacement  of  the  os  innominatum  is  probably 
mainly  brought  about  after  the  child  begins  to  walk. 

Diagnosis. — Slight  degrees  of  deformity  may  be  easily  over- 
looked during  life,  and  even  extreme  degrees  may  only  be  ascer- 


DETAILED   STUDY  OF  INDIVIDUAL   PELVES.  475 

tained  after  careful   examination.     The   following  measurements 
should  always  be  made  with  the  pelvimeter : 

1.  From  the  posterosuperior  spine  of  one  side  to  the  antero- 
superior  spine  of  the  other. 

2.  From  the  posterosuperior  spine  of  one  side  to  the  ischial 
tuberosity  of  the  other. 

3.  From  the  posterosuperior  spine  of  one  side  to  the  tip  of  the 
great  trochanter  of  the  other  side. 

4.  From  each  posterosuperior  spine  to  the  spine  of  the  last 
lumbar  vertebra. 

5.  From  each  posterosuperior  spine  to  the  lower  edge  of  the 
symphysis. 

6.  From  each  posterosuperior  spine  to  a  fixed  point  on  the 
middle  of  the  dorsal  region  of  the  spine. 

On  the  normal  pelvis  these  right  and  left  measurements  in 
each  set  are  equal  or  nearly  equal.  On  a  well-marked  Naegele 
pelvis  there  is  usually  a  difference  of  a  half-inch  or  more  between 
them. 

Careful  internal  examination  of  the  pelvis  should  also  be  made, 
in  order  to  determine  the  relationships  of  the  ischial  spines  and 
tuberosities  to  the  sacrum  on  each  side.  If  the  promontory  can 
be  palpated,  the  hollow  on  each  side  is  felt  to  be  distinctly  narrower 
on  the  affected  side.  The  promontory  also  appears  to  be  slightly 
turned  toward  the  latter. 

Relation  to  Labor. — In  slight  deformity  delivery  may  occur 
spontaneously  with  little  delay.  In  more  marked  contraction  there 
may  be  considerable  interference  with  the  passage  of  the  fetus, 
and  the  mechanism  by  which  the  head  attempts  to  move  through 
the  pelvis  is  the  same  as  that  described  in  the  case  of  the  uni- 
versally contracted  pelvis — /.  e.,  there  is  an  extreme  degree  of 
flexion,  the  shortest  possible  suboccipitobregmatic  circumference 
entering  into  relationship  with  the  pelvic  brim.  Though  the  head 
may  successfully  enter  the  pelvic  cavity,  delay  may  be  caused  when 
the  shoulders  come  into  relationship  with  the  brim,  and  the 
further  movements  of  the  head  may  consequently  be  more  or  less 
interfered  with. 

Treatment. — The  conduct  of  labor  is  the  same  as  that  recom- 
mended in  considering  justo-minor  cases.  When  artificial  de- 
livery is  indicated,  the  axis-traction  forceps  should  be  tried.  Ver- 
sion is  not  usually  advisable  because  of  the  special  risk  of  upward 
extension  of  the  head  and  upper  extremities  at  the  brim.  If  it  be 
carried  out,  that  leg  should  be  brought  down  which  will  cause 
the  occiput  to  be  turned  toward  the  front,  with  the  sagittal  suture 
in  the  larger  oblique. 

In  marked  cases  Ca:isarean  section  may  be  necessary,  or  em- 
bryulcia  if  the  fetus  be  dead.  Premature  labor  may  sometimes  be 
employed    if  the    deformity    is    recognized    in    early   pregnancy. 


476 


ANOMALIES    OF   THE   BONY  PEL  VIS. 


Symphysiotomy  should  not  be  tried,  owing  to  the  possibility  of 
the  existence  of  sacro-iliac  ankylosis. 

4.  Contraction  in  the  Transverse  Diameter  of  the  Pehns. — {a)  As 
a  Result  of  Pressure  or  in  the  Absence  of  BotJi  Sacral  Alee  [Robert 
Pelvis). — Very  rarely  a  deformity  of  the  pelvis  may  result  from 
changes  in  each  wing  of  the  sacrum,  similar  to  those  already  de- 
scribed as  occurring  in  the  Naegele  pelvis.  By  some  it  has  been 
termed  the  double  Naegele  deformity  or  the  double  oblique  con- 
tracted pelvis.  The  wings  of  the  sacrum  may  be  considerably 
altered,  or  the  deficiency  may  be  greater  on  one  side  than  on  the 
other.  SHght  variations  may,  therefore,  be  found  in  the  character- 
istics presented  by  the  Robert  pelvis.  The  ossa  innominata  are 
moved  backward,  inward,  and  a  little  upward,  the  characteristic 
alteration  in  the  pelvis  being  a   diminution   in   all  the  transverse 


Fig.  192.— Transversely  contracted  or  Robert  pelvis,  viewed  from  above  (E.  Martin). 

measurements  of  the  pelvis.  The  ilia  project  more  posteriorly 
than  in  normal  pelves.  The  promontory  lies  a  little  nearer  the 
symphysis,  so  that  there  is  slight  diminution  in  the  conjugate  of 
the  brim  ;  the  sacrum,  as  well  as  being  narrowed,  is  somewhat 
straightened  vertically.  Both  the  sacro-iliac  joints  may  be  anky- 
losed.  The  transverse  diameter  of  the  lozenge  of  Michaelis  is 
greatly  narrowed. 

Relation  to  Labor. — Labor  is  impossible  in  these  pelves,  and 
Caesarean  section  is  always  necessary  if  pregnancy  advances  be- 
yond the  early  rUDntlis. 

(fj)  As  a  Res2ilt  of  Spinal  Kyphosis. — (See  description  of  Ky- 
photic Pelvis.) 

5.  Generally  Compressed  Pelves. — (d)  Malacosteon. — In  a  well- 
marked  malacosteon  pelvis  the  following  are   the   characteristic 


DETAILED   STUDY  OF  INDIVIDUAL    PELVES. 


A77 


peculiarities :  The  iliac  wings  are  bent  from  before  backward,  so 
that  the  normal  relationship  between  the  interspinous  and  inter- 
cristal  diameters  are  markedly  altered.  The  anterosuperior  spines 
are  turned  inward,  and  the  iliac  fossae,  instead  of  being  saucer-like 
as  in  the  normal  pelvis,  are  more  scoop  shaped.     The  brim  has  a 


Fig.  193. — Malacosteon  pelvis,  viewed  from  above  (Winckel). 

somewhat  stellate  or  triradiate  shape,  owing  to  the  approximation 
of  the  promontory  and  the  iliopectineal  eminences.  The  pubic 
bones  lie  close  together  behind  the  symphysis,  forming  a  beak- 
shaped  or  rostrate  projection,  and  the  available  conjugate  of  the 
brim  is  measured  from  the  promontory  to  the  posterior  portion  of 


Fig.  194. — Malacosteon  pelvis,  viewed  from  the  front  (Winckel). 

this  projection.  The  descending  rami  of  the  pubes  are  approxi- 
mated and  may  be  twisted ;  the  subpubic  angle  is,  therefore,  very 
narrow.  The  tuberosities  of  the  ischii  are  usually  nearer  together 
than  normally,  and  one  or  both   may  be  variously  twisted.     The 


478 


ANOMALIES   OF  THE  BONY  PELVIS. 


lower  part  of  the  sacrum  with  the  coccyx  is  curved  upward  and 
inward,  greatly  interfering  with  the  cavity  of  the  pelvis. 

Etiology. — The  pelvic  deformity  is  brought  about  by  the  effects 
of  pressure  at  a  time  when  the  pelvis  is  softened  as  a  result  of  the 
disease  known  as  osteomalacia  or  mollities  ossium. 

It  will  be  readily  understood  that  in  the  altered  condition  of 
the  bones  the  weight  of  the  body  in  a  sitting  posture,  in  standing, 
and  in  walking  may  result  in  such  a  distortion  of  the  pelvis  as  has 
already  been  described. 


Fig.  195. — Pelvis  deformed  slightly  by  osteomalacia  :  a,  Viewed  from  above  ;  b,  viewed 

from  below. 


Diagnosis. — The  condition  is  usually  readily  made  out  by 
physical  examination,  and  a  history  of  osteomalacia  is  generally 
obtained.  The  height  of  the  woman  is  diminished.  The  gait  is 
peculiar,  rotation  of  the  body  usually  taking  place  as  one  foot  is 
advanced  in  front  of  the  other ;  abduction  of  the  limbs  is  difficult 
or  impossible. 

Relation  to  Labor. — During  the  active  progress  of  osteomalacia 


DETAILED   STUDY  OF  INDIVIDUAL    PELVES. 


479 


labor  may  result  in  the  birth  of  the  child  spontaneously  or  with 
assistance,  the  dangers  to  the  mother,  however,  being  consider- 
able. Litzmann  has  collected  the  reports  of  85  cases,  with  a 
maternal  mortality  of  47.  In  pelves  in  which  the  bones  are  hard 
and  the  deformity  fixed,  natural  delivery  is  almost  always  impos- 
sible. 

Treaiinent. — Owing  to  the  marked  maternal  mortality  asso- 
ciated with  delivery  through  pelves  softened  by  osteomalacia,  it  is 
doubtful  if  any  procedure  except  Caesarean  section  is  justifiable, 
though  in  the  past  version  and  forceps  have  been  employed.  The 
abdominal  operation  is  particularly  indicated  in  view  of  the  re- 
searches of  Curatulo  and  others,  who  have  demonstrated  the 
curative  influence  that  the  removal  of  the  ovaries  usually  exerts 
on  the  disease.  This  procedure  should,  therefore,  be  carried  out 
in  conjunction  with  the  conservative  operation   or  with  removal 


Fig.  196. — Pseudomalacosteon  rachitic  pelvis  (Schroeder). 

of  the  uterus.  In  the  hardened  osteomalacic  pelvis  embryulcia 
may  rarely  be  carried  out ;  in  the  great  majority  of  cases  Caesarean 
section  is  necessary. 

{b)  Pseudomalacosteon  Rachitic  Pelvis. — This  deformity  has 
already  been  described  in  connection  with  rickets.  In  it  there 
is  an  approximation  of  the  acetabula  and  the  promontory,  the 
pubic  bones  being  somewhat  approximated  behind  the  symphysis, 
forming  a  kind  of  beak.  The  pelvis  differs  from  the  typical  mala- 
costeon,  however,  in  that  the  iliac  wings  are  not  compressed,  but 
are  found  to  be  markedly  everted  anteriorly,  so  that  the  inter- 
spinous  diameter  is  very  much  greater  than  the  intercristal.  The 
pubic  beak  is  not  so  pronounced  or  narrow  as  in  the  malacosteon 
pelvis,  the  descending  rami  of  the  pubes  and  the  ischial  tuberosi- 
ties are  not  twisted,  and  the  lower  part  of  the  sacrum  does  not 
curve  markedly  upward  into  the  pelvic  cavity. 


480  ANOMALIES    OF   TIJE   BONY  PELVIS. 

6.    Contraction  Associated  ivitli  Deformity  of  the  Spinal  Cord- 


FlG.  197. — Kyphotic  pelvis  and  spine  (Barbour). 


(a)  Kyphosis. — Anteroposterior    bending   of   the  spine,  resulting 
in  the  formation  of  a  posterior  hump,  is  usually  associated  with 


Fig.  198. — Kyphotic  pelvis  (Kleinwachter). 

more  or  less  deformity  in  the  pelvis,  the  alteration  being  most 
marked  when  the  hump  is  pronounced  and  low  in  the  back.    The 


DETAILED   STUDY  OF  INDIVIDUAL    PELVES. 


481 


most  frequent  site  of  the  kyphosis  is  the  junction  of  the  dorsal 
and  lumbar  regions. 

As  a  result  of  the  alteration  in  the  spine,  the  center  of  gravity 
of  the  part  of  the  trunk  above  the  curvature  is  thrown  forward 
when  the  individual  stands  or  sits.  To  counteract  this  some 
degree  of  lordosis  develops  above  the  hump,  but  this  is  insufficient 
to  keep  the  center  of  gravity  in  its  proper  vertical  plane ;  conse- 
quently changes  are  induced  in  the  pelvis  whereby  the  sacrum  is 


199.  Fig.  200. 

Fig.  199. — Advanced  pregnancy  in  a  kyphotic  woman  with  a  justo-minor  pelvis. 
The  belly  is  pendulous,  the  uterus  having  been  unable  to  develop  normally  upward  into 
the  constricted  abdominal  cavity  (Bumm). 

Fig.  200. — Pregnancy  in  a  woman  with  a  justo-minor  pelvis.  The  belly  is  unduly 
prominent  (Bumm). 

gradually  forced  backward  and  downward  in  its  upper  part.  At 
the  same  time  the  lower  end  of  the  bone  is  moved  somewhat  for- 
ward. The  ossa  innominata  are  also  moved  at  the  same  time  and 
may  be  regarded  as  rotating  in  a  transverse  axis,  their  upper  por- 
tions moving  downward  and  backward.  In  the  most  marked 
cases  the  pelvis  has  the  following  characteristics  :  The  inclination 
of  the  brim  is  very  much  diminished,  the  posterior  portion  being 
at  a  relatively  lower  level  than  in  the  normal  pelvis  ;  the  outline  is 


482 


ANOMALIES   OF   THE   BONY  PELVIS. 


somewhat  oval  in  shape,  the  longest  diameter  being  the  antero- 
posterior. There  may  be  no  sign  whatever  of  a  projecting  prom- 
ontory. The  shape  is,  therefore,  exactly  that  of  the  brim  of  the 
newborn  child.  In  addition  to  the  relative  diminution  in  the  length 
of  the  transverse  diameter  there  may  be  some  actual  shortening, 
owing  to  the  diminished  width  of  the  sacrum  that  is  frequently 
found  in  these  cases.  Indeed,  the  latter  bone  may  be  considerably 
altered  from  the  normal,  being  not  only  narrowed,  but  also  elon- 
gated and  somewhat  straightened.  The  pelvic  cavity  becomes 
funnel-shaped,  owing  to  the  approximation  of  the  ischii,  sacrum, 
and  coccyx,  many  different  degrees  of  approximation  being  found. 
In  extreme  cases  the  ischial  tuberosities  may  be  less  than  2  in. 
apart. 

In  the  false  pelvis  the  anterosuperior  spines  are  usually  moved 
somewhat  apart,  while  the  posterior  spines  are  drawn  nearer 
together. 

When  the  last  lumbar  or  upper  sacral  vertebrae  are  affected 
with  the  disease  that  has  caused  the  spinal  curvature,  there  may 
be  some  thickening  of  the  bone,  interfering  with  the  shape  of  the 
brim. 

When  the  curvature  is  very  marked  and  very  low  in  the  back, 
that  part  of  the  spine  projecting  forward  above  the  hump  may 


Fetal  head. 


Spine  of 
isehiiim. 
Ischium. 4v 


Fig.  201. — Head  arrested  by  spines  of  ischia  in  a  kyphotic  pelvis  (Budin). 


encroach  considerably  upon  the  brim,  so  that  it  may  seriously 
interfere  with  the  uterus  and  fetus  in  advanced  pregnancy — the 
so-called  pelvis  obtccta  of  Fehling. 

Diagnosis. — The  deformity  of  the  spine  is  easily  recognized  on 


DETAILED   STUDY  OF  INDIVIDUAL   PELVES. 


483 


examination,  and  careful  pelvimetry  may  determine  the  condition 
of  the  bony  pelvis  ;  when  the  deformity  is  at  all  marked,  it  is 
usually  impossible  to  reach  the  promontory  on  vaginal  examina- 
tion. It  is  especially  necessary  to  examine  the  lower  part  of  the 
pelvic  cavity  and  the  outlet  and  to  note  the  relationship  of  the 
upper  limb  of  the  spinal  curvature  to  the  pelvic  brim. 

Relationship  to  Pregnancy  and  Labor. — Kyphosis  chiefly  affects 
the  pregnant  woman  by  interference  with  the  abdominal  cavity  in 
advanced  gestation.  This  interference  is  most  marked  when  the 
spinal  disease  is  near  the  pelvis  and  when  the  upper  limb  of  the 
curvature  projects  markedly  forward. 

The  growing  uterus  projects  further  forward  than  in  the  normal 


Fk;.  202.  —  Posterior  view  of  a 
woman  with  kyphoscoliosis.  The 
lozenge  of  Michaelis  is  obliquely 
distorted  (Bumm). 


Fig.  203. — Posterior  view  of  a 
woman  with  a  kyphotic  pelvis.  The 
posterosuperior  iliac  spines  are  very 
prominent  (Bumm). 


cases,  and  a  condition  of  well-marked  pendulous  belly  may  be 
produced.  As  a  result  of  this  displacement  of  the  uterus,  malpres- 
entations  and  malpositions  may  be  found  at  the  beginning  of 
labor.  When  these  are  not  present,  however,  no  difficulty  is  met 
with  until  the  head  descends  to  the  lower  part  of  the  pelvic  cavity. 
In  some  cases  this  descent  may  take  place  very  rapidly.  When 
there  is  delay,  the  degree  depends  upon  the  nature  of  the  con- 
traction in  the  lower  portion  of  the  pelvic  cavity  ;  in  slight  cases 
there  may  be  little  prolongation  of  labor.     The  occiput  frequently 


484 


ANOMALIES    OF   THE   BONY  PELVIS. 


tends  to  rotate  to  the  back.  In  most  extreme  conditions  passage 
of  the  fetus  is  impossible. 

After  the  third  stage  there  is  special  danger  of  postpartum 
hemorrhage,  owing  to  the  imperfect  filling  of  the  enlarged  upper 
part  of  the  pelvis  by  the  retracted  and  contracted  uterus. 

Trcatmejit. — In  cases  of  slight  contraction  labor  may  proceed 
naturally,  no  interference  being  necessary.  When  it  is  necessary 
to  use  artificial  means  for  the   purpose  of  delivering  the  head  de- 


FlG.  204. — Diagram  illustrating  the  effect  of  well-marked  kyphosis  on  a  pregnant 
uterus  in  the  late  months.  Extreme  anteversion  of  the  organ  is  produced,  the  fundus 
being  pushed  downward  and  forward  (Tarnier  and  Budinj. 


layed  at  the  lower  part  of  the  pelvis,  forceps  may  be  used,  provided 
the  degree  of  contraction  be  not  too  great  to  prevent  its  safe  appli- 
cation. In  worse  cases  embryulcia  or  Ca^sarean  section  is  indi- 
cated, though,  of  course,  premature  labor  must  always  be  regarded 
as  an  appropriate  measure  in  certain  cases. 

Scoliosis. — The  effects  of  lateral  curvature  of  the  spinal  column 
depend  on  its  situation  and  extent.  Slight  degrees  of  curvature 
situated  high   in   the   spine  may  not  lead  to  any  changes  in  the 


DETAILED   STUDY  OF  INDIVIDUAL    PELVES.  485 

pelvis.  When  situated  near  the  latter,  the  effects  on  the  pelvis 
are  usually  more  or  less  marked. 

Most  cases  of  extreme  scoliosis  are  due  to  rachitis,  and  conse- 
quently the  pelvic  bones  present  the  features  that  have  already 
been  described  in  connection  with  that  disease.  In  this  connection 
it  is  only  necessary  to  refer  to  the  pelvic  alterations  resulting  from 
the  spinal  deformity. 

The  center  of  gravity  of  the  body  is  displaced  toward  that  side 
of  the  pelvis  over  which  the  convexity  of  the  spinal  curvature 
projects.  There  is,  therefore,  a  tendency  to  oblique  compression 
of  the  pelvis,  which  is  aggravated  especially  during  sitting  and 
walking.  The  acetabulum  corresponding  to  the  limb  that  receives 
the  greatest  share  of  the  body-weight  is  forced  somewhat  upward 
and  inward  toward  the  sacrum  and  the  overhanging  spinal  con- 


FlG.  205. — Grooves  on  head  of  fetus,  caused  by  pressure  against  the  ischial  spines  as  it 
passed  through  a  kyphotic  pelvis  (Lelievre). 

vexity.  At  the  same  time  there  is  some  rotation  of  the  lumbar 
vertebrae  toward  the  side  of  the  convexity. 

The  shortest  diameter  of  the  pelvic  inlet  thus  becomes  the 
sacrocotyloid — /.  c,  the  distance  between  the  promontory  and  the 
iliopectineal  eminence  ;  in  some  cases,  however,  this  diameter  must 
be  drawn,  not  from  the  promontory,  but  from  the  nearest  point 
on  the  projecting  lumbar  convexity.  The  lozenge  of  MichaeHs  is 
somewhat  asymmetric. 

Relationship  to  Labor. — In  very  slight  degrees  of  scoliosis  there 
may  be  no  interference  with  the  normal  mechanism  of  labor.  In 
other  cases  trouble  arises  in  proportion  to  the  degree  of  curva- 
ture and  the  pelvic  changes  associated  with  rachitis.  In  some 
cases  the  latter  are  predominant  and  naturally  influence  the  nature 
of  the  delivery.     When  the  sacrocotyloid  diameter  is  much  short- 


486 


ANOMALIES    OF   THE   BONY  PELVIS. 


ened,  a  considerable  part  of  the  pelvic  inlet  may  be  of  no  avail  for  the 
passage  of  the  head,  which  may  attempt  to  pass  a  large  portion  of 
the  brim  by  a  mechanism  similar  to  that  which  takes  place  in  the 
generally  contracted  pelvis.  In  such  cases,  however,  only  an 
unusually  small  fetus  may  succeed  in  entering  the  pelvic  cavity. 
In  all  cases  in. which  artificial  delivery  is  necessary  the  indications 

are  practically  the  same  as 
those  described  in  connection 
with  rachitic  flat  pelves. 

Kyphoscoliosis. — As  a  result 
of  marked  rachitic  changes, 
kyphosis  and  scoliosis  may  be 
present  at  the  same  time. 
When  the  lower  part  of  the 
spine  is  affected,  the  pelvis 
may  be  somewhat  altered  to 
correspond  with  both  forms 
of  curvature.  As  a  rule, 
in  these  cases  the  kypho- 
sis is  situated  in  the  dorsal 
region,  so  that  the  pelvis  may 
not  be  markedly  affected  by  it. 
Lordosis. — Marked  antero- 
posterior curvature  of  the 
spine,  producing  a  forward 
convexity,  is  extremely  rare 
as  a  primary  disease.  It  is 
usually  found  compensatory 
to  other  spinal  or  pelvic  de- 
formitory.  If  it  is  situated  low 
in  the  lumbar  region,  it  may 
interfere  with  the  normal  rela- 
tionship of  the  uterus  to  the 
pelvic  brim  in  pregnancy  and 
with  the  normal  entrance  of 
the  fetus  into  the  pelvis  during 
labor. 

7.  Alterations  of  the  Pekns 
Resulting  from  Tumors,  In- 
juries, and  Disease. — All  tu- 
mors that  grow  from  bone — 
i.  e.,  fibroma,  sarcoma,  carcinoma,  etc. — may  be  found  in  the  pelvis, 
and  by  diminishing  the  size  of  the  brim  or  the  cavity,  may  interfere 
with  labor.  Exostoses  are  occasionally  found,  especially  in  the  re- 
gion of  the  various  joints,  and  may  produce  swellings  sufficient  to 
interfere  seriously  with  the  passage  of  the  fetus,  as  well  as  being 
the  source  of  injury  to  the  maternal  soft  parts  and  the  fetal  tissues. 


Fig.  206. — Kyphoscoliosis  (Leopold). 


DETAILED   STUDY  OF  INDIVIDUAL    PELVES. 


487 


They  are  most  frequent  in  rachitic  pelves.  Double  dislocation 
backward  of  the  thigh  bones,  usually  congenital,  is  a  rare  condi- 
tion. It  produces  rotation  forward  of  the  upper  part  of  the 
sacrum  and  a  widening  of  the  lower  part  of  the  pelvic  cavity,  the 
ischial  tuberosities  being  moved  somewhat  outward,  upward,  and 
backward. 

Fractures  of  the  pelvis  are  also  rare,  but  may  result  in  pelvic 
deformity  as  a  result  of  faulty  union  of  the  bones,  callous  formation. 


Fig.  207. — Kyphoscoliotic  rachitic  pelvis  (Ahlfeld). 


and  ossification  of  joints  near  the  fracture.  Ankylosis  of  one  or 
more  pelvic  joints  may  occasionally  be  found  ;  when  the  coccyg- 
eal joints  are  affected,  there  may  be  considerable  interference  with 
the  passage  of  the  fetus  through  the  outlet.  Fracture  may 
result,  and  this  may  be  followed  by  faulty  union,  necessitating  later 
removal. 

When  the  symphysis  pubis  is  ankylosed,  the  difficulty  of  per- 
forming symphysiotomy  is  increased.  When  the  sacro-iliac  joints 
are  affected  in  early  life,  the  condition  is  chiefly  of  importance  in 
relation  to  the  development  of  the  adjacent  portions  of  the  sacrum 
and  ilium,  a  deficiency  in  these  causing  an  oblique  contraction  of 
the  pelvis. 

Relationship  to  Labo7\ — It  is  very  evident  that  labor  maybe  in- 
terfered with  in  various  degrees  according  to  the  alteration  pro- 
duced in  the  bony  passage.  In  some  cases  delivery  may  only  be 
prolonged  ;  in  other  cases  it  may  be  impossible. 


488 


ANOMALIES   OF  THE  BONY  PEL  VIS. 


All  the  well-recognized  methods  of  artificial  delivery  may  be 
necessary  in  these  conditions. 

8.  Deformities  of  the  Pelvis  in  Relation  to  the  PostpartJivi  Utej'us. 
— In  the  author's  work  on  the  normal  postpartum  state  he  has 
pointed  out  that  immediately  after  the  third  stage  the  retracted 
and  contracted  body  of  the  uterus  acts  as  a"  ball-plug,"  filling  the 
greater  portion  of  the  pelvic  cavity  and  compressing  the  extra- 
uterine tissues   laterally  against  the  bony  wall,  while  inferiorly. 


Fig.  208. — Luxation  and  paralysis  of  right  lower  limb  (Winckel). 


owing  to  the  softened  and  relaxed  state  of  the  pelvic  floor,  there 
is  very  much  less  compression  of  the  extra-uterine  tissues.  As  a 
result  of  this  relationship  the  circulation  of  the  blood  external  to 
the  uterus  is  considerably  interfered  with  in  the  upper  part  of  the 
pelvis,  while  in  the  lower  part  the  vessels  are  less  interfered  with, 
the  various  tissues  being  more  or  less  congested,  like  the  adjacent 
cervix  ;  while  the  tissues  in  the  upper  part  of  the  pelvis  are  more 
or  less  anemic,  like   the  body  of  the  uterus.     This  condition  re- 


DETAILED   STUDY   OF  INDIVIDUAL    PELVES. 


489 


mains  practically  unaltered  during  the  first  four  days  of  the  puer- 
perium,  and  undoubtedly,  owing  to  this  compression  of  vessels  as 
well  as  to  the  retraction  and  contraction  of  the  uterine  body,  the 
risk  of  hemorrhage  from  the  inner  surface  of  the  uterus  is  reduced 
to  a  minimum. 

The  condition  of  the  tissues  in  the  lower  part  of  the  pelvis 
makes  it  easy  to  understand  why,  after  delivery,  bleeding  is  likely 
to  result  from  tears  in  the  cervix,  vagina,  or  "neighboring  tissues. 
Careful  observations  regarding  the  postpartum  state  in  women 
with  contracted  pelves  make  it  evident  that  hemorrhage  is  apt  to 


Fig.  209. — Cystic  enchondroma 
(Zweifel). 


Fig.  210. 


-Button-like  exostosis   on   prom- 
ontory (Schauta). 


be  more  marked  than  in  women  with  normal  pelves,  the  reason 
being  that  the  uterus  cannot  sink  within  the  pelvic  cavity  if  the 
contraction  be  marked,  and  that  consequently  the  normal  plugging 
of  the  cavity  is  absent.  Stratz  has  published  sections  of  a  woman 
with  a  well-marked  rickety  pelvis  who  died  of  postpartum  hemor- 
rhage half  an  hour  after  labor.  The  uterus  remained  almost 
entirely  above  the  brim,  the  various  tissues  of  the  pelvis  being 
thereby  allowed  to  become  greatly  congested. 

On  the  other  hand,  in  kyphotic  pelves  and  abnormally  large 
pelves  the  risk  of  postpartum  bleeding  is  increased,  for  though 
the  uterus  may  sink  within  the  pelvis,  it  cannot  act  as  a  plug  in 


490 


ANOMALIES    OF   THE   BONY  PELVIS. 


the  enlarged  cavity,  the  extra-uterine  tissues,  therefore,  remaining 
abnormally  congested.  Barbour,  of  Edinburgh,  has  pubHshed  a 
case  of  a  woman  with  a  kyphotic  pelvis  who  died  of  postpartum 
hemorrhage  one  and  a  half  hours  after  delivery,  and  his  sections 
demonstrate  the  condition  that  has  just  been  described. 

Prevention  of  Dystocia. — In  the  nineteenth  century  various 
attempts  were  made  to  diminish  the  size  of  the  fetus  by  measures 
carried  out  during  pregnancy,  in  order  that  labor  might  be  made 
less  difficult  in  cases  in  which  there  had  previously  been  dystocia. 

These  methods  consisted  of  bleeding  or 
purging  the  woman  or  in  reducing  her 
diet. 

In  1 84 1  Rowbotham,  a  London 
chemist,  published  an  account  of  the 
dietetic  measures  that  he  had  employed 
with  satisfaction  in  the  case  of  his  own 
wife.  His  aim  was  to  exclude  those 
mineral  ingredients  that  enter  into  the 
structure  of  bone.  This  diet  was  com- 
posed largely  of  substances  containing 
vegetable  acids  (apples,  grapes,  lemons, 
and  oranges),  which  were  intended  to 
prevent  the  deposit  of  earthy  salts. 
Small  quantities  of  bread,  rice,  and 
potatoes  were  allowed,  and  scarcel}- any 
animal  food. 

Though  his  work  attracted  some  at- 
tention among  the  public,  little  notice 
was  paid  it  by  the  medical  profession. 
In  1889  Prochownick  published  an 
account  of  several  cases  in  which  diet- 
etic restrictions  appeared  to  produce 
satisfactory^  results. 

Florshiitz,  Hoffmann,  Reijenga,  Has- 
pels,  von  Swiecicki,  and  others  have 
made  similar  statements  within  recent 
years.  Prochownick  and  his  followers 
believe  that  it  is  possible,  by  diminish- 
ing the  diet  in  pregnancy,  to  produce  a 
smaller  fetus,  with  an  increased  capacity  for  head-moulding.  In 
a  series  of  48  cases,  representing  62  confinements,  in  which  the 
conjugate  of  the  brim  varied  from  3^  to  4  in.,  he  found  that  labor 
occurred  normally  at  full  term,  whereas  previously  instrumental 
delivery  or  the  induction  of  premature  labor  had  been  employed. 
He  advises  it  with  a  conjugata  vera  of  not  less  than  8  cm. 

The  diet  recommended  during  the  last  two  or  three  months 
of  pregnancy  is  as  follows : 


Fig.  211, — Congenital  luxa- 
tion of  both  femora :  C,  Crest 
of  ilium  ;  F,  trochanter  of  femur 
(Henry). 


DETAILED   STUDY  OF  INDIVIDUAL    PELVES. 


491 


Breakfast. — Small  cup  of  coffee  and  25  gm.  of  toast  or  Zwie- 
back with  butter. 

Dinner. — Any  kind  of  meat,  an  egg,  fish  with  sauce,  some 
green  vegetables  prepared  in  fat,  salad,  and  cheese. 

Stipper. — The  same  as  dinner,  with  the  addition  of  40  to  50 
gm.  of  bread ;  butter  as  desired. 

The  total  quantity  of  fluids  taken  is  not  to  exceed  500  c.c, 
of  which  300  to  400  c.c.  may  be  red  wine  or  Moselle. 

Slight  changes  are  permitted  to  suit  individual  tastes,  such  as  the 
substitution  of  the  same  quantity  of  milk  or  water  for  the  alcohol, 
along  with  some  fresh  fruit.  Also  a  small  cup  of  coffee  or  tea 
with  15  to  20  gm.  of  bread  or  one  ^^^  might  be  taken  in  the 


Fig.  212. — Bony  tumor  of  pelvis  (Winckel). 

afternoon.      Soups,  potatoes,  cereals,  sugar,  beer,  and  water  in 
quantities  are  to  be  entirely  avoided. 

It  is  interesting  to  note  in  this  connection  the  recent  experi- 
ments of  Noel  Paton,  who  found  in  the  case  of  well-fed  pregnant 
guinea-pigs  that  each  gram  of  the  mother's  weight  produced  from 
0.35  to  0.4  gm.  of  fetus  ;  while  in  the  case  of  an  underfed  animal 
each  gram  of  the  mother  produced  only  0.22  gm.  of  fetus. 


CHAPTER    IV. 

ANOMALIES  OF  THE  PASSENGER. 

Malpositions  of  the  Head. — Various  malpositions  of  the 
head  may  be  found  in  cases  of  deformed  pelves,  tumors,  and 
other  conditions.  These  will  be  considered  in  other  sections. 
Here    attention    need  be    given    only    to    the    consideration    of 


492  ANOMALIES    OF   THE   PASSENGER. 

occipitoposterior  positions  of  the  head,  all  other  conditions  being- 
normal. 

OCCIPITOPOSTERIOR  CASES. 

It  has  been  already  stated  that  in  cases  of  vertex  presentations 
the  long  axis  of  the  head  at  the  beginning  of  labor  lies  in  an 
oblique  diameter  of  the  pelvis.  Those  cases  in  which  the  occiput 
is  anterior  have  already  been  described.  (See  Normal  Labor.) 
Rarely  the  occiput  is  posterior  :  occipitodextra  posterior  (O.  D.  P.), 
most  frequent ;   occipitolaeva  posterior  (O.  L.  P.). 

Nature  of  the  I/abor. — Labor  is  usually  longer  than  in 
occipito-anterior  cases,  because  as  the  head  advances  flexion  tends 
to  be  less  well  preserved,  owing  to  the  resistance  of  the  posterior 
bony  pelvic  wall  against  the  occipital  end  of  the  head,  and  because 
in  the  movement  of  internal  rotation  the  occiput  traverses  a 
greater  distance.  The  pains  are  often  irregular.  The  membranes 
frequently  rupture  prematurely. 

Diagnosis. — On  palpating  the  abdomen  at  the  beginning  of 
labor  the  back  of  the  fetus  is  not  usualh'  felt.  Sometimes  it  may 
be  partly  felt  between  the  iliac  crest  and  the  last  rib.  If  the  wall 
be  thin  or  lax,  the  irregular  projections  of  its  limbs  may  easily  be 
distinguished  through  the  anterior  abdominal  wall.  If  the  head 
be  above  the  pelvic  brim,  the  rounded  occiput  is  not  felt  anteriorly. 
The  anterior  shoulder  may  be  felt  3  or  4  in.  from  the  middle  line. 
Sometimes  the  sharp  chin  may  be  felt  anteriorly.  The  fetal  heart 
may  be  heard  in  the  lumbar  region,  well  around  toward  the  back, 
between  the  ribs  and  iliac  crest ;  frequently,  however,  the  dorsal 
surface  of  the  fetus  is  too  posterior  to  allow  the  heart  to  be  heard. 
On  vaginal  examination  the  vertex  is  palpated  through  the  fornix. 
When  there  is  some  dilatation  of  the  cervix,  the  sagittal  suture 
may  be  distinguished  in  the  oblique  diameter.  The  posterior 
fontanel  may  be  felt  near  the  sacro-iliac  joint,  though  sometimes 
it  cannot  be  touched  early  in  labor.  The  anterior  fontanel  may 
be  found  near  the  iliopectineal  eminence. 

Mechanism. — As  the  head  descends  the  posterior  fontanel 
tends  to  leave  the  girdle  of  contact  and  to  move  downward  and 
inward  toward  the  axis  of  the  canal.  This  is  generally  described 
as  flexion,  and  has  always  been  thought  to  be  due  to  a  bending  of 
the  chin  on  the  sternum.  There  is,  however,  no  proof  that  this 
occurs.  If  the  head  undergoes  any  such  movement,  the  body 
probably  undergoes  a  corresponding  change  on  its  long  axis. 
This  dipping  of  the  occiput  takes  place  more  slowly  than  in 
occipito-anterior  cases,  because  there  is  more  resistance  to  the 
descent  of  the  occiput  than  in  anterior  vertex  cases,  the  broad 
biparietal  end  of  the  head  being  in  relation  to  the  narrowed  part 
of  the  brim  external  to  the  promontory.  As  the  posterior  end 
of  the  head  reaches  the  sacral  segment  of  the  pelvic  floor,  the 


ABNORMAL    OCCIPITOPOSTERIOR    CASES. 


493 


movement  of  internal  rotation  begins  in  accordance  with  Berry 
Hart's  law,  the  occiput  being  shunted  forward  until  it  lies  in  the 
middle  line  behind  the  symphysis.  The  labor  thereafter  proceeds 
as  in  an  occipito-anterior  case,  extension  and  external  rotation  of 
the  head  occurring. 

Abnormal  Occipitoposterior  Cases. — Occasionally  there 
is  a  divergence  from  the  normal  mechanism  just  described. 

(i)  When  the  pelvis  is  very  roomy  or  the  fetal  head  is  small, 
the  latter  enters  the  pelvis  less  flexed  than  normally  and  descends 
more  rapidly.  In  such  a  case  the  sinciput  may  reach  the  sacral 
segment  of  the  pelvic  floor  anteriorly  before  the  occiput  reaches 
it  behind,  and  in  accordance  with  Hart's  law  is  rotated  to  the  front, 
the  posterior  part  of  the  head  moving  toward  the  hollow  of  the 
sacrum.  Clinically  this  change  is  usually  described  as  a  back- 
ward rotation  of  the  occiput,  though  in  reality  the  essential  feature 
is  anterior  rotation  of  the  anterior  part  of  the  head.     After  this 


Fig.  213, 


-Occipitoposterior  position,  witli  the  head  beginning  to  distend  the  pelvic 
floor  (Smellie). 


malrotation  there  may  be  much  delay,  the  case  being  termed 
"persistent  occipitoposterior  "  or  "  face  to  pubes."  When  labor 
continues,  the  occiput  descends  over  the  perineum,  the  face  passing 
under  the  symphysis.  It  is  the  more  satisfactorily  accomplished 
when  the  pains  are  strong,  the  head  very  small,  and  the  maternal 
tissue  soft  and  relaxed.  The  head  flexes  markedly  as  it  passes 
through  the  outlet.  After  the  head  is  born  the  body  usually 
rotates  so  as  to  deliver  the  shoulders  anteroposteriorly  (described 
as  external  rotation  of  the  head).  The  perineum  is  greatly 
stretched  and  is  usually  badly  torn.  The  moulding  of  the  head 
in  such  cases  consists  in  shortening  of  the  occipitomental  and 
occipitofrontal  diameters  and  in  lengthening  of  the  suboccipito- 
brcgmatic. 

(2)  In  some  cases  the  occiput  early  in  labor  meets  with  great 
resistance  at  the  pelvic  brim,  so  that  the  normal  flexion  is  undone, 
the  presentation  being  changed  to  that  of  a  face  or  brow. 


494  ANOMALIES    OF   THE   PASSENGER. 

(3)  In  other  cases  the  movement  of  internal  rotation  may  be 
checked  when  the  long  diameter  of  the  head  lies  in  the  transverse 
diameter  of  the  pelvis.  This  may  be  due  to  inefficiency  in  the 
pains,  but  may  also  be  found  as  a  result  of  partial  extension  of 
the  head. 

Management  of  I^abor. — The  case  must  be  closely  watched, 
frequent  vaginal  examinations  being  made  to  determine  whether 
or  not  the  head  enters  the  pelvis  properly  flexed.  When  the 
progress  is  satisfactory,  the  management  is  the  same  as  in  occipito- 
anterior cases. 

When  extension  tends  to  take  place,  the  sinciput  should  be 
pushed  up  with  the  fingers  during  the  pains.  If  this  be  not  suc- 
cessful   after    several    attempts,    various    procedures    are    recom- 


FlG.  214. — Expulsion  of  head  in  persistently  posterior  positions  of  occiput;  mechanism 
of  face-to-pubes  dehvery. 

mended.  Some  advise  that  the  patient  should  be  deeply  anesthe- 
tized while  a  hand  is  passed  through  the  dilated  cervix,  pressing 
up  the  sinciput,  while  the  fetus  is  pushed  downward  through  the 
abdomen.  If  flexion  is  brought  about  in  this  way,  the  anesthesia  is 
discontined,  and  the  fetus  is  pressed  downward  until  pains  return, 
in  order  that  the  head  may  be  kept  in  its  new  position. 

Some  recommend  grasping  the  head  and  rotating  it  until  the 
occiput  is  anterior,  the  sinciput  being  pushed  upward  in  order  to 
flex  the  head,  the  body  being  also  turned  correspondingly  by 
manipulations  through  the  abdomen.  Labor  may  then  be  allowed 
to  continue  normally  or  forceps  may  be  applied.  Others  prefer  to 
apply  forceps  to  the  head  early  when  the  occiput  lies  posteriorly. 
Many  advise  delivery  by  version  in  all  cases  in  which  extension 


FACE   PRESENTATIONS.  495 

tends  to  take  place  at  the  end  of  the  first  stage.  When  the  head 
is  partially  rotated  or  malrotated  within  the  pelvis,  it  is  sometimes 
possible,  by  the  introduction  of  a  hand  into  the  vagina,  to  rotate 
the  occiput  to  the  front,  the  body  undergoing  a  corresponding 
change. 

Application  of  Forceps. — When  the  forceps  is  used  in  a 
high  occipitoposterior  case,  the  blades  are  applied  in  the  usual 
manner — /.  c,  right  and  left,  as  regards  the  pelvis.  The  head  is 
usually  grasped  obliquely.  As  descent  occurs  rotation  tends  to 
take  place.  This  results  in  damage  to  the  maternal  tissues  from 
the  ends  of  the  blades,  since  the  latter  are  turned  so  as  to  be  ill 
adapted  to  the  pelvic  curve.  The  instrument  should,  therefore, 
be  removed  before  rotation  reaches  the  danger-point.  It  should 
be  reapplied  to  the  head  in  its  new  position.  As  the  occiput  is 
well  rotated  toward  the  front  the  case  may  be  left  to  nature,  or 
the  forceps  may  be  removed  and  again  applied. 

When  the  forceps  is  applied  in  a  low  occipitoposterior  case,  the 
grasp  of  the  head  varies  according  to  the  position  of  the  head. 
When  the  latter  has  rotated  slightly  or  not  at  all,  the  blades  hold 
it  obliquely  ;  when  the  long  diameter  lies  transversely,  it  is  grasped 
over  the  face  and  occiput ;  in  such  cases  rotation  occurs  as  traction 
is  made.  If  this  is  marked,  the  instrument  should  be  removed  and 
reapplied.  Between  tractions  the  handles  should  be  separated,  in' 
order  to  give  the  occiput  an  opportunity  to  turn  to  the  front,  as  it 
sometimes  does  spontaneously.  When  the  instrument  is  applied 
to  the  head  whose  occiput  has  rotated  into  the  sacral  hollow,  a  safe 
transverse  grasp  is  obtained.  The  sinciput  should  be  pushed  up 
as  much  as  possible  before  the  blades  are  introduced.  As  the 
head  is  delivered  the  patient  should  be  placed  in  Walcher's  posi- 
tion, in  order  to  relax  the  perineum.  Episiotomy  should  be  carried 
out  if  necessary  to  prevent  a  central  rupture.  In  all  conditions 
axis-traction  forceps  must  be  used.  Recently  Milne  Murray  has 
designed  a  special  axis  -traction  forceps  for  use  in  occipitoposterior 
cases.  The  chief  modification  consists  in  a  lessening  of  the  pelvic 
curve,  in  order  that  when  rotation  of  the  head  occurs  extraction 
may  be  continued,  removal  and  reapplication  of  the  instrument 
not  being  necessary,  since  the  ends  of  the  blades  do  not  project 
so  as  to  injure  the  maternal  tissues. 

FACE  PRESENTATIONS. 

Cases  of  labor  in  which  the  fetus  presents  by  its  face  are  very 
rare.  Their  frequency  is  variously  estimated,  and  might  be  placed 
between  i  in  175  and  i  in  250. 

Positions. — The  chin  is  used  to  denominate  face  positions, 
which  are  described  as  follows,  in  order  of  frequency  :  Mento- 
dcxtra    posterior    fM.    D.    P.),    mentolaeva    anterior   (M.    L.   A.), 


496 


ANOMALIES   OF   THE   PASSENGER. 


mentolaeva  posterior  (M.  L.  P.),  mentodextra  anterior  (M.  D.  A.). 
By  some  writers  it  is  stated  that  left  mento-anterior  positions  are 
more  frequent  than  right  mentoposterior.  Some  authors  state 
that  in  face  and  brow  cases  the  long  diameter  of  the  head  always 
lies  transversely. 

Htiology. — Face  presentations  are  best  regarded  as  vertex 
presentations  in  which  extension  of  the  head  has  occurred.  They 
may  exist  before  labor  begins,  but,  as  a  rule,  develop  during 
labor.  The  following  causes  may  be  mentioned  :  i .  New  growths 
or  other  enlargements  of  the  neck  and  chest ;  tonic  contraction 
of  the  neck  muscles.  2.  Displacement  of  the  arms  under  the 
chin.  3.  Coiling  of  the  cord  several  times  around  the  neck.  4. 
Smallness  or  mobility  of  the  fetus.  5.  Hydramnios ;  amniotic 
bands.  6.  Sudden  escape  of  the  amniotic  fluid.  7.  Displace- 
ment of  the  long  axis  of  the  uterus.  8.  Contractions  of  the  pelvic 
brim.  9.  Certain  occipitoposterior  cases  in  which  there  is  much 
resistance  to  the  descent  of  the  occiput. 

Some  authors  state  that  an  elongated  or  dolichocephalic  head 
causes  face  presentations,  owing  to  the  increased   resistance   of 

the  posterior  half  of  the  head 
against  the  brim  of  the  pelvis, 
but  it  is  very  doubtful  if  this 
shape  of  head  is  ever  suffi- 
ciently marked  in  iitcro  to  cause 
the  malpresentation.  This  type 
of  head  is  usually  found  after 
delivery  in  face  cases,  but  the 
shape  must  be  regarded  as  due 
to  the  moulding  resulting  from 
the  peculiar  mechanism  of 
labor. 

By  several  authors  face  pres- 
entations have  been  stated  to  be 
more  frequent  in  primiparae  than 
in  multiparae.  The  researches 
of  Winckel  and  Pinard,  however, 
show  that  they  are  more  com- 
mon among  the  latter. 
Diagnosis. — On  examining  the  mother's  abdomen  early  in 
labor  the  conditions  presented  differ  somewhat  from  those  found 
in  corresponding  vertex  cases.  In  mentoposterior  cases,  if  the 
abdominal  wall  be  lax,  it  is  usually  possible  to  feel  the  high 
occiput  and  the  depression  between  the  occiput  and  the  back  of 
the  fetus  resulting  from  the  extension  of  the  head  above  Poupart's 
ligament ;  in  mento-anterior  cases  it  may  rarely  be  felt  in  the 
flanks.  The  chin  may  frequently  be  distinctly  felt.  The  fetal 
limbs,  the  heart,  and  the  least  accessible  part  of  the  head  are 


Fig.  215. 


-Presentation   of  face  at  pelvic 
brim. 


FACE  PRESENTATIONS.  497 

found  on  the  same  side,  the  heart  sounds  being  transmitted 
through  the  ventral  side  of  the  chest.  The  head  is  well  above 
the  brim.  On  vaginal  examination  in  the  beginning  of  labor  the 
fornix  is  higher  than  in  normal  cases  and  is  irregularly  flattened 
transversely,  the  normal  rounded  bulging  found  in  vertex  cases 
being  absent. 

When  the  cervix  is  dilated,  the  fingers  may  distinguish  various 
portions  of  the  face — i.  e.,  nose,  malar  processes,  supra-orbital 
ridges,  and  cavity  of  the  mouth.  When  the  soft  tissues  are  much 
swollen  and  altered,  it  is  more  difficult  to  distmguish  these  parts, 
and  the  face  may  be  mistaken  for  the  breech,  the  mouth  being 
regarded  as  the  anus,  the  nose  as  the  coccyx,  the  malar  processes 
as  the  ischial  tuberosities,  and  the  cheeks  as  the  nates.  In  making 
a  digital  examination  the  eyes  may  easily  be  injured  if  too  much 
force  be  employed.  Ordinarily  the  plane  of  the  face  is  parallel  to 
the  plane  of  the  brim,  but  occasionally  it  may  be  obliquely  placed, 
so  that  much  more  of  one  side  may  be  palpated  than  of  the  other. 

Prognosis. — Labor  is  delayed  both  in  the  first  and  second 
stages.  The  face  does  not  fit  the  lower  uterine  segment  as 
accurately  as  does  the  vertex,  and  does  not  allow  of  the  formation 
of  so  satisfactory  a  bag  of  membranes.  The  latter  may  pouch 
downward  abnormally  and  may  rupture  prematurely.  Mento- 
posterior cases  are  usually  slower  than  mento-anterior.  In  the 
former  malrotation  of  the  chin  into  the  hollow  of  the  sacrum  is 
apt  to  occur,  producing  a  serious  complication  that  generally  de- 
mands interference.  The  risk  to  the  mother  in  face  cases  is 
slightly  greater  than  in  vertex  cases ;  the  fetus  is  in  much  greater 
danger,  the  percentage  of  risk  being  computed  as  13  to  5.  Lacera- 
tion of  the  perineum  is  very  common. 

Mechanism  of  I/abor. — A  normal  mechanism  may  be  de- 
scribed in  face  cases. 

(a)  Mento=anterior  Cases. — As  the  head  enters  the  pelvis  the 
frontomental  diameter  tends  to  lie  somewhat  in  the  transverse. 
As  descent  continues  extension  continues,  owing  to  the  marked 
resistance  offered  to  the  downward  movement  of  the  occiput  by 
the  pelvic  wall.  That  part  of  the  presenting  part  that  first  reaches 
the  sacral  segment  of  the  pelvic  floor  is  the  chin,  and  in  accord- 
ance with  Hart's  law  it  is  rotated  to  the  middle  line  anteriorly. 
In  the  most  common  anterior  case  (M.  L.  A.),  therefore,  the  chin, 
reaching  the  anterior  portion  of  the  left  half  of  the  sacral  segment, 
is  moved  around  to  the  symphysis.  Flexion  of  the  head  then 
gradually  takes  place,  the  mouth,  nose,  and  forehead  appearing 
successively  under  the  pubes,  while  the  vertex  sweeps  over  the 
perineum,  followed  by  the  occiput.  Afterward  external  rotation 
occurs,  being  a  movement  of  the  shoulders,  whereby  they  are 
made  to  lie  in  the  anteroposterior  diameter  of  the  outlet.  They 
are  then  delivered,  followed  by  the  rest  of  the  body. 


498 


ANOMALIES   OF   THE   PASSENGER. 


{b)  Mentoposterior  Cases. — Here  extension  of  the  head  as 
descent  continues  causes  the  chin  to  reach  the  posterior  part  of 
the  sacral  segment  of  the  floor  and  to  be  rotated  around  to  the 
front,  the  extent  of  internal  rotation  being  much  greater  than  in 
mento-anterior  cases.  The  rest  of  the  delivery  is  the  same  as  in 
mento-anterior  cases. 

Abnormal  Cases. — {ci)  In  mentoposterior  cases  rotation  of  the 
head  may  occur  so  that  the  chin  is  turned  into  the  hollow  of  the 
sacrum.  According  to  Hart,  this  takes  place  when  the  pelvis  is 
abnormally  large  or  the  head  small.  Extension  of  the  head  is 
less  marked  than  in  a  normal  face  case.  The  chin  does  not  first 
reach  the  sacral  segment  of  the  pelvic  floor,  but  the  sinciput 
reaches  the  opposite  segment  and  is  rotated  to  the  front.  In  other 
words,  that  which  we  describe  clinically  as  a  movement  of  the 
chin  to  the  back  is  in  reality  a  forward  rotation  of  the  sinciput. 
When  this  complication  occurs  natural  delivery  rarely  takes  place, 
except  after  great  delay  and  danger  both  to  mother  and  fetus. 


Fin.  216. — Posterior  position  of  face  deeply  engaged  in  pelvis  (Smellie). 

The  reason  of  this  is  simple.  The  end  of  the  chin  is  pressed 
firmly  into  the  hollow  of  the  sacrum,  and  if  the  head  be  normal 
in  size  or  somewhat  enlarged,  it  is  evident  that  birth  can  occur 
only  by  excessive  stretching  of  the  sacrosciatic  ligaments  and 
perineum,  bending  of  the  coccyx,  and  compression  of  the  cranial 
vault  of  the  fetal  head.  The  malrotated  condition  is  usually  de- 
scribed as  a  "  persistent  mentoposterior  "  case. 

{li)  Very  rarely  when  the  pelvis  is  unusually  large  or  the  head 
small,  the  fetus  may  be  forced  through  the  birth  canal  without 
any  special  mechanism. 

Moulding  of  the  Head. — After  a  face  delivery  the  occipito- 
frontal, occipitomental,  and  transverse  diameters  of  the  head  are 
increased  and  the  suboccipitobregmatic  lessened.  The  vault  of 
the  head  is  flattened,  the  frontals  more  bulged,  and  the  occipital 
bone  pushed  somewhat  backward.  The  face  is  swollen  by  the 
caput  succedaneum.     The  latter  varies  in   position  according  to 


FACE   PRESENTATIONS.  499 

the  nature  of  the  case.  In  mento-anterior  positions  it  is  placed 
in  the  region  of  the  angle  of  the  mouth  (thus,  in  M.  L.  A.  cases, 
on  the  left  side  of  the  face).  In  mentoposterior  positions  it  is 
situated  in  the  upper  malar  region  and  orbit  (in  M.  D.  P.  cases,  on 
the  right  side  of  the  face).  In  other  words,  the  caput  forms  over 
that  part  of  the  face  situated  anteriorly  in  relation  to  that  portion 
of  the  pelvis  where  there  is  the 
least  pressure  against  it.  There 
may  be  marked  discoloration  of 
the  skin  from  blood-extravasa- 
tion ;  the  eye  may  remain  closed 
several  days  after  birth,  and  the 
mouth  may  be  so  swollen  as  to 
prevent  the  child  from  nursing. 
The  attitude  tends  to  be  that  of 
opisthotonos  for  some  days. 

Management  of  I^abor. — 
Face  cases  must  be  watched  care- 
fully throughout  labor.    The  bag 

of  membranes  must  be  preserved  fig.  217.— Configuration  of  fetal  head 
as  long  as  possible,  since  the  face  ^^^^^  *'^  '^^"^^''y  ^^  ^  ^^^^^  presentation, 
acts  as  a  poor  dilator.  In  a  multi- 
para with  a  roomy  pelvis  and  soft,  dilatable  tissues  the  case  may 
be  left  to  nature,  especially  when  the  chin  is  anterior.  The  patient 
should  be  made  to  lie  mainly  on  the  side  toward  which  the  chin 
is  directed.  If  internal  rotation  is  slow,  it  may  be  assisted  by 
pressing  the  chin  forward  with  the  fingers  during  pains. 

In  mentoposterior  cases  some  form  of  interference  is  usually 
advisable.  Some  authors  recommend  that  the  patient  should  be 
anesthetized  when  the  diagnosis  is  made,  and  an  effort  be  made 
to  change  the  face  to  a  vertex  presentation  by  combined  external 
and  internal  manipulations.  In  a  mento-anterior  case  this  should 
not  be  done,  because  an  occipitoposterior  position  would  be  pro- 
duced, and  this  might  not  be  more  favorable  to  satisfactory  de- 
livery. 

Schatz  recommends  the  following  method :  The  head  must  be 
mobile  and  not  impacted  in  the  brim,  and  no  condition  must  be 
present  calling  for  rapid  delivery.  The  patient  lying  on  her  back, 
the  operator  stands  on  the  side  toward  which  the  occiput  is 
directed.  Between  pains  the  anterior  shoulder  is  grasped  by  the 
hand  corresponding  to  it,  and  the  breech  by  the  other.  Pressure 
is  exerted  on  the  shoulder  in  the  direction  of  the  occiput  and 
somewhat  upward,  the  breech  being  pressed  upward  and  toward 
the  anterior  surface  of  the  fetus.  The  hands  at  first  press  at  a 
right  angle  to  each  other,  then  parallel  in  opposite  directions, 
and  afterward  the  breech  is  pushed  downward  and  laterally, 
When  pains  come  on,  the  head  is  steadied.     When  the  head  is  in 


500  ANOMALIES   OF   THE   PASSENGER. 

proper  position,  the  patient  may  be  placed  on  her  side  correspond- 
ing to  the  anterior  surface  of  the  fetus,  or  the  membranes  may  be 
ruptured  to  prevent  the  head  from  moving. 

Baudelocque  recommended  two  procedures.  In  carrying  out 
one  the  operator  stands  on  the  side  corresponding  to  the  fetal 
occiput  and  introduces  the  hand  corresponding  to  the  fetal  face 
into  the  genital  passage,  the  cervix  being  dilated,  and  grasps  the 
face  or  upper  jaw,  forcing  it  in  the  direction  of  the  chin — /.  c, 
flexes  the  head  ;  at  the  same  time  the  outer  hand  presses  the 
occiput  down  into  the  pelvic  inlet. 

In  his  second  procedure  the  operator  stands  on  the  side  toward 
which  the  chin  and  breast  lie,  and,  introducing  his  hand  into  the 
uterus,  grasps  the  occiput  and  pulls  it  down,  while  with  the  outer 
hand  he  pushes  the  chest  of  the  fetus  upward  and  to  the  opposite 
side. 

Humphrey  advocates  the  genupectoral  posture  in  carrying  out 
this  method.  These  internal  manipulations  are  most  difficult 
when  the  pelvis  is  contracted.  There  is  considerable  risk  of 
rupturing  the  cervix  and  lower  uterine  segment.  The  greatest 
caution  must,  therefore,  be  employed. 

Ziegenspeck,  in  employing  Baudelocque's  first  procedure,  used 
an  assistant  to  push  the  child  aside  from  without,  according  to 
Schatz's  method. 

If  a  vertex  presentation  can  be  satisfactorily  brought  about,  the 
case  may  be  left  to  nature,  or  forceps  may  be  used  if  the  head 
does  not  tend  to  engage  well,  provided  that  the  cervix  is  suf- 
ficiently well  dilated.  If  it  is  not  possible  or  advisable  to  bring 
about  a  vertex  presentation,  delivery  by  version  may  be  employed. 
But  if  this  be  inadvisable,  the  axis-traction  forceps  may  be  applied 
when  the  chin  is  anterior.  Forceps  application,  however,  is  a 
difficult  and  dangerous  procedure,  and  is  to  be  undertaken  only 
as  a  last  resort  when  a  living  child  is  greatly  desired.  The  blades 
must  be  applied  right  and  left  as  regards  the  pelvis,  no  matter 
how  the  face  is  placed.  It  is  very  evident  that  their  grip  of  the 
fetus  is  bad  and  that  they  are  so  ^^'ide  apart  that  they  are  \&vy 
apt  to  injure  the  maternal  soft  parts.  In  mentoposterior  cases 
forceps  should  not  be  applied,  because  if  the  head  descends,  it  is 
practically  certain  that  the  chin  will  pass  into  the  hollow  of  the 
sacrum.  Owing  to  the  progress  made  in  the  operation  of  sym- 
physiotomy, it  is  recommended  by  various  authorities  that  this 
operation  should  be  carried  out  in  mentoposterior  cases  when 
delay  has  occurred  before  an  attempt  is  made  to  use  forceps. 
When  the  fetus  is  dead,  it  is  always  advisable  to  perform  em- 
bryulcia.  If  the  head  has  entered  the  pelvis  and  labor  is  delayed, 
in  spite  of  the  efforts  to  promote  extension  and  internal  rotation, 
the  child's  life  is  always  endangered  by  the  stretching  of  the 
vessels  and  nerves  of  the  neck  and  by  the  pressure  against  them. 


BKOIV  PRESENTATIONS.  5OI 

In  such  cases  labor  must  be  artificially  terminated,  either  by  forceps 
application,  with  or  without  symphysiotomy,  or  by  embryulcia. 
It  is  very  dangerous  to  the  fetus  to  use  forceps  in  such  conditions, 
because  the  blades  are  apt  to  press  on  the  tissues  of  the  neck. 

When  labor  is  delayed  by  rotation  of  the  chin  into  the  hollow 
of  the  sacrum,  the  patient  should  be  anesthetized  and  an  effort 
made  to  rotate  the  head  by  the  hand  introduced  into  the  vagina. 
If  this  is  impossible  and  the  child  be  alive,  forceps  delivery  may  be 
recommended,  though  the  risk  to  the  fetus  and  to  the  maternal 
tissues  is  very  great.  The  patient  should  always  be  placed  in 
Walcher's  position  when  the  instrument  is  used,  in  order  to 
diminish  the  risk  of  lacerating  the  perineum  extensively.  Sym- 
physiotomy is  also  justifiable  when  this  complication  exists.  If 
the  child  is  dead,  however,  embryulcia  may  be  carried  out. 

BROW  PRESENTATIONS. 

Presentations  of  the  brow  are  much  rarer  than  those  of  the 
face.  In  24,582  labors  at  Guy's  Hospital  there  were  14  (i  in 
1756).  They  may  be  regarded  as  halfway  stages  in  the  trans- 
formation of  vertex  to  face  presentations  by  extension  of  the  head. 
The  most  frequent  position  is  that  in  which  an  O.  L.  A.  vertex 
has  been  altered ;  the  next  most  frequent  that  in  which  an  O.  D. 
P.  has  been  changed.  It  is  not  necessary  to  give  special  denomi- 
nations, however,  to  these  different  brow  positions.  Some  authors 
hold  that  in  most  cases  the  long  axis  of  the  head  lies  transversely 
at  the  beginning  of  labor. 

etiology. — The  causes  of  head  extension  are  the  same  as 
those  described  in  connection  with  face  presentations. 

Diagnosis. — On  abdominal  examination  at  the  beginning  of 
labor  the  conditions  are  somewhat  different  from  those  found  in 
corresponding  vertex  cases,  but  an  exact  diagnosis  may  be  very 
difficult  by  this  method.  The  head  is  high,  the  occiput  and  chin 
being  on  the  same  level  and  easily  palpated.  The  heart  is  usually 
heard  through  the  back  of  the  fetus. 

After  the  cervix  is  dilated,  digital  examination  may  find  the  root 
of  the  nose,  the  supra-orbital  ridges,  the  forehead,  and  sometimes 
the  anterior  fontanel.  When  marked  swelling  of  the  soft  tissues 
of  the  forehead  occurs,  it  is  very  difficult  to  feel  the  bony  parts 
satisfactorily. 

Mechanism  of  I^abor. — i.  A  normal  mechanism  may  be 
described,  but  it  is  very  rare  and  occurs  only  when  there  is  not 
too  great  a  disproportion  between  the  head  and  the  pelvis.  This 
process  is  very  lengthy.  As  the  head  descends  through  the  inlet 
the  occipitomental  diameter  is  diminished.  The  brow  reaches  the 
sacral  segment  of  the  floor  and  is  rotated  anteriorly  to  the  middle 
line  below  the  pubes,  the  face  lying  behind  the  latter,  the  occiput 
being  in  tlic  hollow  of  the  sacrum.     P^lcxion  then  takes  place,  the 


502 


ANOMALIES    OF   THE   PASSENGER. 


vertex  sweeping  over  the  perineum,  then  the  nose,  mouth,  and  chin 
passing  under  the  pubes.  External  rotation  then  occurs,  the 
shoulders  being  born,  followed  by  the  body,  as  in  a  vertex  case. 

2.  When  the  child  is  very  small  or  the  pelvis  very  roomy,  the 
former  may  be  pushed  through  without  any  special  mechanism. 

3.  Sometimes  a  brow  presentation  may  be  changed  to  a  vertex 
or  a  face  early  in  labor  and  may  have  the  mechanism  of  either  of 
these. 

Moulding  of  the  Head. — When  the  fetus  is  born  after  the 
normal  mechanism  just  described,  there  is  a  characteristic  altera- 
tion of  the  head.  The  caput  succedaneum  extends  from  the  nose 
to  the  top  of  the  forehead,  the  latter  being  somewhat  flattened 
vertically;  from  the   forehead  the  vertex   slopes  downward  and 

backward  to  the  occipital  re- 
gion. On  profile  the  head  has 
a  somewhat  triangular  shape, 
the  forehead  being  much  elon- 
gated vertically.  When  a  case 
has  commenced  as  a  brow  and 
ended  as  a  face,  the  head  is 
dolichocephalic,  with  a  caput 
succedaneum  on  the  forehead 
as  well  as  on  the  face. 

Management. — If  a  brow 
presentation  be  diagnosed  early 
in  labor,  it  should  never  be  al- 
lowed to  continue  unchanged. 
An  effort  should  be  made  to 
change  it  to  a  vertex,  pressure 
being  made  on  the  sinciput  with  the  fingers  during  pains,  or  the 
methods  of  Schatz,  Baudelocque,  and  others,  as  used  in  face 
cases,  may  be  employed.  The  case  may  then  be  left  to  nature  or 
forceps  may  be  applied.  If  a  vertex  presentation  cannot  be  brought 
about,  it  is  advisable  to  perform  version  if  the  condition  of  the 
uterus  is  favorable.  Some  recommend  that  a  face  presentation 
should  be  brought  about.  This  is  not  advisable  if  a  mentopos- 
terior is  produced.  If  a  mento-anterior  be  produced,  there  is  less 
objection  to  bringing  about  a  face  presentation.  Transformation 
to  a  face  presentation  should,  however,  be  considered  only  if  the 
vertex  cannot  be  substituted  or  if  version  is  impossible.  When 
these  procedures  cannot  be  carried  out  it  is  advisable  to  employ 
forceps  if  the  cervix  be  dilated,  though  this  method  of  treatment 
is  unfavorable  for  the  child  and  is  apt  to  injure  the  maternal  soft 
parts.  If  the  child  be  alive,  symphysiotomy  is  justifiable  previous 
to  forceps  application.  If  the  child  be  dead,  embryulcia  should  be 
performed.  When  the  head  has  entered  the  pelvis  and  labor  is 
delayed,  the  forceps  may  be  used,  though  this  method  is  very 


Fig.  218. — Configuration  of  fetal  head 
after  its  delivery  as  a  brow  presenta- 
tion. 


PELVIC  PRESENTATIONS.  503 

unsatisfactory,  especially  when  the  chin  is  posterior.  It  is  advis- 
able to  treat  this  condition  as  that  of  a  face  case  delayed  in  the 
pelvis. 

PELVIC  PRESENTATIONS. 

Frequency. — Different  statistics  are  given  as  to  the  frequency 
of  pelvic  presentations.  Pinard  states  that  they  occur  once  in 
every  30  labors  ;  though  if  miscarriages  and  premature  births  be 
excluded,  the  percentage  is  i  in  60.  Generally  the  breech  presents  ; 
occasionally  one  or  both  knees  or  feet  may  be  lowermost.  In 
order  of  frequency  the  positions  are  :  Sacrolseva  anterior  (S.  L. 
A.),  sacrodextra  posterior  (S.  D.  P.),  sacrodextra  anterior  (S.  D. 
A.),  sacrolaeva  posterior  (S.  L.  P.). 

It  is  thus  evident  that  the  positions  are  denominated  by  the 
sacrum.  Berry  Hart,  however,  objects  to  this  nomenclature.  The 
sacrum  is  unimportant  in  the  study  of  the  mechanism  of  labor,  and 
he  urges  that  the  hip  should  be  employed  in  the  denomination  of 
positions,  since  it  is  the  movement  of  that  part  which  is  chiefly 
studied  in  the  mechanism  of  labor. 

Ktiolog^y. — The  cause  of  pelvic  presentations  is  not  always 
evident.  It  is  undoubtedly  favored  by  a  number  of  conditions — 
e.  g.,  hydramnios,  laxity  of  the  uterine  and  abdominal  walls,  dis- 
placement of  the  long  axis  of  the  uterus,  multiparity,  multiple 
pregnancy,  monstrosity,  death  or  prematurity  of  delivery,  placenta 
prsevia,  contracted  pelvis,  and  tumors  of  the  uterus  or  other 
tissues. 

Diagnosis. — On  abdominal  examination,  unless  the  parietes 
be  too  thick  or  tense  or  the  uterus  be  abnormally  distended 
with  amniotic  fluid,  the  head  may  be  palpated  in  the  upper 
part  of  the  uterus.  The  breech  may  be  felt  in  the  lower  por- 
tion ;  it  is  not  found  within  the  pelvis  before  labor  begins.  It 
forms  a  mass  that  is  not  so  firm  as  the  head,  is  more  variable  in 
consistence,  and  has  a  less  distinct  outline.  The  breech  can  be 
moved  only  along  with  the  body,  there  being  no  independent  move- 
ment as  there  is  to  a  certain  extent  in  the  case  of  the  head.  Along 
with  the  lower  limbs  it  has  usually  a  somewhat  irregular  con- 
formation ;  the  latter  are  more  in  evidence  when  the  back  is  pos- 
terior. When  they  are  moved  by  the  hands,  the  point  about 
which  movement  occurs  is  at  a  lower  level  than  the  free  moving 
parts.  The  fetal  heart-sounds  are  heard  above  the  middle  of  a 
vertical  line  joining  the  fundus  and  the  pubes,  where,  as  in  head 
presentations,  they  are  heard  below  this  point. 

On  examining  the  vagina  early  in  labor  the  normal  bulging  of 
the  hard  fetal  head  is  absent,  though  in  some  cases  it  may  be 
very  difficult  to  state  that  the  projection  is  not  the  head.  The 
head  of  an  anencephalic  monster  may  closely  resemble  a  breech. 
After  the  cervix  has  dilated  somewhat  the  various  structures  of 


504 


ANOMALIES   OF  THE  PASSENGER. 


the  breech  may  be  distinguished — e.  g.,  the  coccyx,  ischial  tuber- 
osities, the  feet  if  they  present,  or  the  knees  ;  the  foot  must  be 
distinguished  from  the  hand  by  its  length,  the  presence  of  a  pro- 
jecting OS  calcis,  the  parallel  toes,  and  the  absence  of  an  opposable 
thumb.  When  both  feet  are  down,  they  usually  lie  together. 
The  knee  may  be  mistaken  for  the  elbow,  but  is  larger  and  lacks 
the  short  olecranon.  The  anus  is  usually  felt  as  a  dimple  below 
the  level  of  the  skin.  When  the  child  is  dead,  however,  the  anus 
may  be  gaping  and  project  as  an  eminence.  If  the  child  be  a  male, 
the  penis  and  scrotum  may  be  distinguished.  The  latter  may  be 
mistaken  for  the  bag  of  membranes,  especially  if  it  be  much 
swollen  by  the  presence  of  a  caput  succedaneum.  In  the  case  of 
a  female  the  anus  may  be   mistaken  for  the  cervix.     Holmes  and 


Os  int.  1  cervical 
Osext.  J      canal. 

Uterovesical  peri- 

toneutn. 
—  Bladder. 

Symphysis  pubis. 

■;  Vagina. 

Fig.  219. — Full-time  pregnancy.      Breech  presentation.     Reconstruction  from   frozen 

sections  (Waldeyer). 

Others  have  reported  instances  in  which  it  has  been  wrongly 
dilated.  If  the  finger  be  passed  between  the  thigh  and  the  ab- 
domen, the  groin  may  be  mistaken  for  the  axilla,  but  it  is  distin- 
guished from  it  by  the  absence  of  ribs.  Meconium  may  be  found 
in  the  vaginal  discharge.  It  has  a  tarry  consistence  and  may  be 
abundant.  In  describing  face  cases  it  has  been  pointed  out  that 
presentation  of  the  latter  may  be  mistaken  for  a  breech,  especially 
when  the  caput  succedaneum  has  been  formed  over  it. 

Prognosis. — In  uncomplicated  cases  the  risks  to  the  mother 
are  not  greater  than  in  vertex  cases.  Dangers  arise  chiefly  from 
methods  of  interference  that  may  be  employed.     Frequently  in- 


PEL  VIC  PRESENTA  TIONS. 


505 


ertia  of  the  uterus  is  produced  by  too  rapid  extraction.  Separation 
of  the  placenta,  loss  of  blood,  and  laceration  of  the  cervix  and 
pelvic  floor  may  be  brought  about. 

The  risks  to  the  child  are  considerable,  the  fetal  mortality 
being  high.  Hegar  had  a  mortality  of  35,  Ramsbotham  of  18.7, 
and  Pinard  of  19.5  per  cent.  The  cord  is  often  prolapsed  and 
pressed  upon  ;  the  liquor  amnii  is  apt  to  escape  early,  because  the 
breech  does  not  fit  so  well  into  the  lower  uterine  segment  as  does 
the  head,  and,  the  forewaters  being  not  completely  shut  off  from 
the  rest  of  the  liquor  amnii,  the  membranes  are  apt  to  be  ruptured 
by  the  force  of  the  uterine  contractions.  Separation  of  the  placenta 
may  occur  in  hurried  delivery  or  prolonged  compression  of  the 
cord  may  take  place,  and  thus  the  fetus  may  die  from  asphyxia 


Fig.  220. — Passage  of  buttocks  through  vulva  in  a  breech  case  (A.  R.  Simpson). 


slowly  or  rapidly.  It  may  make  attempts  at  respiration  and  draw 
fluids  into  its  lungs.  Fractures  and  dislocations  of  the  long  bones 
may  be  produced  by  manipulations.  Koettnitz  states  that  wry- 
neck and  hematoma  of  the  sternomastoid  muscle  occur  more  fre- 
quently in  breech  cases  than  in  any  other.  Other  muscles  may 
be  the  seat  of  hemorrhages.  Internal  ruptures  and  hemorrhages 
may  be  produced.  The  brachial  plexus  may  be  injured  by  traction 
on  the  shoulders. 

Mechanism  of  I/abor. — A  normal  mechanism  of  labor  in 
breech  cases  may  be  described  as  follows  :  As  descent  occurs  the 
hips  may  descend  on  the  same  level  or  the  anterior  hip  may  be  a 
little  lower  than  the  po.sterior.  The  former  reaches  the  sacral 
segment  of  the  floor  and  is  rotated  to  the  middle  line  anteriorly. 


5o6 


ANOMALIES   OF   THE  PASSENGER. 


It  then  remains  for  a  time  just  behind  the  lower  margin  of  the 
symphysis,  while  the  rest  of  the  pelvis  is  pushed  downward,  the 
posterior  hip  moving  forward  over  the  perineum  ;  the  anterior  hip 
then  gradually  moves  downward  and  forward,  followed  by  the  rest 
of  the  trunk  and  extremities,  the  latter  being  usually  flexed  on  the 
anterior  part  of  the  body.  The  lower  limbs  may  not  be  bent  at 
the  knees,  or  may  be  straightened  out  over  the  anterior  surface  of 
the  body.  This  attitude  is  apt  to  produce  some  delay  in  labor,  as 
Tarnier  has  pointed  out,  because  the  straight  legs  act  as  splints, 
interfering  with  the  normal  flexion  of  the  trunk  and  its  accommo- 
dation to  the  pelvic  curve.     In  some  cases  only  one  leg  is  straight- 


FiG.  221. — Delivery  of  fetus  in  a  breech  case  by  pressure  on  the  fundus  uteri  and  by 
traction  on  the  lower  limbs  (A.  R.  Simpson). 

ened,  the  other  being  in  its  normal  attitude  of  flexion.  As  the 
shoulders,  reach  the  outlet  they  rotate  so  that  their  long  diameter 
changes  from  the  transverse  to  the  anteroposterior  of  the  pelvis. 
The  head  is  born  flexed,  its  anteroposterior  diameter  passing  the 
brim  in  the  oblique  or  transverse  diameter.  As  it  descends  in  the 
cavity  it  rotates  so  that  the  occiput  lies  behind  the  pubes,  the  face 
being  in  the  hollow  of  the  sacrum.  The  face  then  descends  over 
the  perineum,  followed  by  the  rest  of  the  head. 

Moulding  of  the  Fetus. — The  breech  is  usually  swollen  by 
a  caput  succedaneum  and  there  may  be  much  discoloration.     The 


PELVIC  PRESENTATIONS.  507 

swelling  is  mainly  over  the  hip  that  has  been  anterior  in  labor,  but 
may  spread  to  the  rest  of  the  breech,  and  in  the  case  of  a  male 
fetus  may  markedly  affect  the  scrotum.  If  the  knees  or  feet 
present,  they  also  may  be  swollen. 

Variations  in  the  Mechanism. — i.  In  some  cases  the 
breech  may  be  delayed  at  the  brim,  especially  when  it  is  very  large 
or  when  the  latter  is  somewhat  contracted. 

2.  Delay  may  occur  after  the  breech  has  entered  the  bony 
pelvis,  due  to  smallness  of  the  latter,  large  size  of  the  fetus,  con- 
traction of  the  cervix,  or  extension  of  the  lower  limbs  of  the  fetus 
on  its  anterior  surface. 

3.  Frequently  the  arms  are  displaced  upward.  This  may  be 
caused  by  contraction  of  the  cervix  on  the  body  of  the  fetus  as  it 
descends,  but  it  also  results  from  too  hurried  emptying  of  the 
uterus  when  artificial  delivery  is  carried  out.  Displacements  of 
the  upper  and  lower  extremities  are  frequently  combined.  One  or 
both  arms  may  be  displaced  upward  and  may  be  found  in  various 
positions  in  relation  to  the  head — in  front,  behind,  or  at  the  sides. 
This  complication  delays  labor  and  usually  demands  immediate 
interference,  because  the  life  of  the  child  is  endangered,  owing  to 
the  extra  pressure  likely  to  be  exerted  on  the  umbilical  cord. 

4.  Impaction  of  the  head  may  take  place  above  the  brim  or 
within  the  cavity  of  the  pelvis.  This  is  usually  due  to  extension 
from  too  rapid  delivery,  though  it  may  be  caused  by  a  large  head 
or  by  contraction  of  the  pelvis.  In  some  cases  rotation  of  the 
anterior  hip  of  the  fetus  does  not  occur  and  the  body  passes 
directly  through  the  brim,  the  shoulders  being  in  relation  to  the 
transverse  diameter.  As  the  head  descends  anterior  rotation  of 
the  occiput  may  not  occur,  and  it  may  lie  at  the  side  of  the  pelvis 
or  may  turn  to  the  back.  Within  the  pelvis  also  the  head  may 
only  partially  rotate  and  may  become  jammed  in  the  transverse 
diameter.  In  other  cases,  owing  to  extension  of  the  head,  the 
chin  may  get  fixed  in  the  hollow  of  the  sacrum. 

General  Management. — Breech  cases  must  be  carefully 
watched  from  the  beginning.  As  long  as  the  normal  conditions 
exist  no  interference  should  be  carried  out,  though  recently  some 
authors  have  advocated  external  version  for  the  purpose  of 
changing  the  breech  to  a  vertex  presentation.  The  case  may 
often  continue  throughout  with  a  satisfactory  termination.  When 
dilatation  of  the  cervix  is  very  slow,  especially  if  there  is  prema- 
ture rupture  of  the  membranes  or  artificial  pouching  down- 
ward of  them  so  that  they  are  inefficient,  it  is  advisable  to  assist 
dilatation  by  the  use  of  Barnes's  bag  or  that  of  Champetier 
de  Ribcs,  nature  being  allowed  to  complete  the  delivery  after 
dilatation  is  ended.  When  the  umbilicus  appears,  a  loop  of  the 
cord  should  be  examined,  in  order  to  determine  the  condition  of 
the  circulation.     If  the  latter  be  satisfactory,  labor  may  be  allowed 


5o8 


ANOMALIES   OF   THE   PASSENGER. 


to  proceed  by  natural  means.  The  exposed  portion  of  the  fetus 
may  be  covered  with  a  warm  cloth  and  supported.  As  the  hands 
appear  at  the  vulva  they  may  be  withdrawn.  The  cord  should 
again  be  examined,  and  if  its  pulsations  are  weak  or  have  ceased, 
delivery  should  be  hastened.  Sometimes  spasms  of  the  body  of 
the  child  are  present,  indicating  that  respiratory  efforts  are  being 
made ;  they  always  indicate  that  there  must  be  no  delay.  In 
order  to  hasten  labor  it  is  advisable  to  use  suprapubic  pressure 
through  the  fundus  uteri  as  well  as  to  employ  traction  from  below. 
In  practice  much  too  great  prominence  is  given  to  the  latter 
factor,  the  former  being  frequently  forgotten.  This  neglect  is  very 
apt  to  lead  to  some  of  the  accidents  that  have  already  been 
described.     The  child  should  be  withdrawn  from  the  pelvis  in  the 


Fig.  222. 


-Examining  umbilical  cord  during  course  of  a  breech  delivery 
(A.  R.  Simpson). 


proper  axis  of  the  outlet.  When  it  is  found  that  a  loop  of  the 
cord  lies  between  the  thighs  of  the  fetus,  an  effort  should  be  made 
to  pull  it  down  and  slip  it  up  over  the  posterior  thigh.  If  this  be 
impossible,  or  if  the  cord  be  wound  tightly  around  the  body,  it 
should  be  tied  in  two  places  and  divided,  delivery  being  thereafter 
hastened. 

In  carrying  out  manipulations  in  a  breech  case  it  is  advisable 
that  the  patient  should  be  placed  at  the  edge  of  the  bed  or  on  a 
table. 

Management  in  Complications. —  i.  Non=engagement 
at  the  Brim. — When  the  breech  does  not  enter  the  inlet,  Kristel- 
ler's  manipulation  may  be  employed  if  the  cervix  be  well  dilated. 


PEL  VIC  FRESENTA  TIONS. 


509 


If  this  fails,  a  lower  limb  should  be  drawn  down,  provided  the 
cervix  or  the  bony  canal  be  large  enough  to  admit  this.  Gentle 
traction  accompanied  with  downward  pressure  against  the  fundus 
of  the  uterus  maybe  made  for  a  short  time,  and  then  nature  may 
be  allowed  to  continue  the  delivery  ;  but  if  the  patient  has  been 
long  in  labor  and  is  tired,  or  if  the  life  of  the  fetus  be  threatened, 
continued  artilicial  delivery  must  be  employed.  An  assistant 
should  press  down  the  fetus  through  the  abdominal  wall,  and  the 
foot  should  gradually  be  drawn  down,  the  limb  enveloped  in  a 
sterile  cloth,  being  held  as  close  to  the  vulva  of  the  mother  as 


Fig.  223. — Delivery  of  fetus  in  a  breech  case  by  traction  made  witli  fingers  placed  in 
groin  (A.  R.  Simpson). 

possible.  Traction  should  be  made  intermittently  and  pressure 
against  the  pubic  arch  should  be  avoided  as  much  as  possible. 
When  the  breech  descends  to  the  perineum,  it  should  be  directed 
somewhat  forward  in  the  axis  of  the  outlet.  As  the  abdomen  is 
delivered  the  other  limb  usually  drops  down.  The  rest  of  the 
labor  may  be  carried  out  as  in  normal  cases. 

2.  Impaction  of  the  Breech. — When  the  breech  is  delayed 
after  having  entered  the  pelvic  cavity,  labor  may  be  hastened  in 
various   ways.     Kristcllcr's   manipulation   may  be   tried.     If  this 


510 


ANOMALIES    OF   THE   PASSENGER. 


fail,  the  index-finger  may  be  placed  in  an  accessible  groin  of  the 
fetus,  preferably  the  anterior,  in  order  to  pull  it  down.  Instead 
of  the  fingers  a  sterile  gauze  fillet  may  be  used.  The  fillet  may 
be  passed  with  the  fingers,  or  with  a  gum-elastic  catheter  threaded 
with  a  loop  of  string.  A  blunt  hook  is  used  by  some  for  the 
purpose  of  extraction,  but  it  may  injure  the  tissues.  The  direction 
of  traction  should  be  toward  the  fetal  pelvis,  in  order  that  injury 
of  the  thigh  may  be  avoided.  When  these  measures  fail,  forceps 
may  be  applied  to  the  breech,  but  this  method  may  be  attended 
with  risk  to  the  fetal  tissues.     It  is  necessary  to  compress  them  to 


Fig.  224. — Method  of  freeing  the  posterior  arm  displaced  upward  in  a  breech  deUvery 

(A.  R.  Simpson). 


a  certain  extent  with  the  blades.  When  all  other  means  fail,  it  is 
necessary  to  perform  symphysiotomy  or  embryulcia.  In  the 
latter  case  the  pelvis  may  be  perforated  with  a  cranioclast  in 
order  to  obtain  a  good  grip  ;  sometimes  crushing  with  a  cephalo- 
tribe  is  necessary.  As  the  head  is  drawn  down  it  should  also  be 
perforated,  to  render  its  passage  more  easy  and  to  insure  death 
of  the  fetus. 

3.  Upward  Displacement  of  the  Arms. — {a)    Wlicn  the  Head 
is  still  Above  the  Brim. — When   labor  is  delaved  owino-  to  dis- 


PEL  VIC  PRESENTA  TIONS 


511 


Fig.  225. — Method  of  freeing  the  anterior  arm  displaced  upward  in  a  breech  delivery 

(A.  R.  Simpson). 

placement  of  the  arms  above  the  brim,  jamming  usually  occurs 
when  that  part  of  the  thorax  which  is  normally  at  the  lower  ends 
of  the  scapulse  lies  at  the  level  of  the  vulva.     In  order  to  free  the . 


Fig.  226. — Diagrams  illustrating  the  method  of  withdrawing  an  arm  that  has  been  dis- 
placed upward  during  a  breech  delivery  (Budin  and  Crouzat). 

arms  the  body  of  the  fetus  should  be  pushed  a  little  upward, 
to  lessen  the  pressure  at  the  brim,  and  the  trunk  should  be 
rotated  so  that  the  back  lies  toward  one  or  the  other  side  of  the 


512  ANOMALIES    OF  THE   PASSENGER. 

mother.  It  should  then  be  pressed  well  forward  against  the 
pubes,  in  order  that  the  arm  which  is  situated  posteriorly  should 
be  first  freed.  In  bringing  this  about  a  hand  is  passed  into  the 
vagina  behind  the  fetus,  and  the  first  two  fingers  are  pushed  up 
behind  the  neck  of  the  fetus  as  far  as  the  elbow  of  the  posterior 
arm.  The  latter  is  then  carried  down  over  the  face  of  the  fetus 
until  it  comes  to  lie  in  the  pelvic  cavity,  traction  being  made  only 
in  the  hollow  of  the  elbow.  The  fetus  is  then  pushed  backward 
against  the  perineum  and  the  anterior  arm  freed  by  a  similar 
maneuver.  When  the  latter  procedure  is  impossible  on  account 
of  the  lack  of  space  in  which  to  work,  the  body  of  the  fetus  may 
be  rotated  by  both  hands  placed  on  the  thorax,  the  latter  being 
first  pushed  upward  in  order  to  diminish  the  risk  of  dislocating 
the  neck.  If  the  child  be  satisfactorily  turned,  the  anterior  arm 
is  made  to  lie  posteriorly  and  may  then  be  more  easily  drawn 
down. 

{b)  Wlicii  the  Head  is  Bcloiv  the  Brim. — In  this  position  the 
arms  are  more  easily  drawn  down  than  when  the  head  is  above 
the-  brim,  unless  the  pelvis  be  small  or  the  fetus  abnormally  large. 
The  posterior  arm  is  usually  withdrawn  first,  but  if  the  anterior 
arm  is  most  accessible,  it  may  be  first  released.  In  carrying  out 
these  manipulations  there  is  always  a  risk  of  dislocating  the 
humerus,  of  separating  the  upper  epiphx'sis  of  the  humerus,  of 
fracturing  the  humerus,  clavicle,  or  scapula,  or  of  injuring  nerves. 
When  it  is  impossible  to  release  the  arms,  cleidotomy  (division  of 
the  clavicle)  may  be  performed,  in  order  to  diminish  the  size  of  the 
shoulder-girdle. 

4.  Constriction  of  the  Fetus  by  the  Uterus. — The  cervix 
may  sometimes  retract  firmly  on  the  neck  or  the  retraction  ring 
may  grasp  the  head  of  the  fetus.  Either  complication  endangers 
the  life  of  the  fetus  by  compressing  the  cord,  and  immediate  de- 
livery is  necessary.  Under  deep  anesthesia  traction  must  be 
made  on  the  shoulders  and  mouth,  accompanied  by  suprapubic 
pressure,  or  forceps  must  be  applied  to  the  after-coming  head  if 
the  soft  parts  can  be  sufficiently  dilated  to  permit  its  safe  applica- 
tion. 

5.  Impaction  of  the  Head. — The  head  may  become  impacted 
at  the  inlet  or  within  the  cavity  of  the  pelvis.  In  such  cases  de- 
livery may  be  accomplished  by  the  following  methods  : 

{A)  Manual  Extraction. — [a)  By  the  Sniellie  Grasp. — The  bod)' 
of  the  fetus  is  placed  on  the  anterior  aspect  of  the  physician's 
forearm,  its  legs  hanging  down,  one  on  each  side.  The  fingers 
of  this  hand  are  introduced  into  the  vagina  and  placed  on  each 
side  of  the  nose.  The  fingers  of  the  other  hand  are  passed 
upward  over  the  back  as  far  as  the  base  of  the  skull.  Flexion 
of  the  head  is  brought  about  by  pulling  down  with  the  fingers 
that  are  on  the  face  and  pushing  up  with  those  resting  against 


PEL  VIC  PRESENTA  TIONS. 


513 


the  occiput.  The  body  of  the  fetus  is  then  raised  gradually  over 
the  pubes  as  the  head  is  drawn  down,  the  face  sweeping  over  the 
perineum. 


Fig.  227. — Delivery  of  after-coming  head  by  combined  traction  on  head  and  shoulders. 

ib)  By  the  Prague  Grasp. — The  feet  are  grasped  in  one  hand, 
so  that  the  trunk  can  be  drawn  well  back  over  the  mother's 
perineum.     The  fingers  of  the  other  hand  are  then  placed  over 


Pig.  228. — Prague  method  of  extracting  after-coming  iiead,  superior  strait. 

the  shoulders,  traction  being  made  downward  by  both  hands,  the 
body  being   carried  forward  gradually  as  the  face  is  drawn  over 

tlic  perineum. 


5H 


ANOMALIES   OF  THE   PASSENGER. 


{c)  Mauriceau  or  Smellie-Veit  Grasp. — Two  fingers  of  one 
hand  are  placed  in  the  mouth  of  the  fetus,  while  those  of  the 
other  hand  grasp  the  shoulders.  The  fetus  is  drawn  downward 
at  first  and  the  body  afterward  carried  gradually  toward  the  pubes. 
Too  much  force  must  not  be  exercised  in  pulling  on  the  lower 
jaw,  lest  fracture  or  dislocation  result. 

{d)  Wig  and- Martin  Method. — The  body  of  the  fetus  is  placed 
astride  the  anterior  aspect  of  the  arm,  while  the  fingers  are  placed 


Fig.  229. 


-Delivery  of  after-coming  head  by  flexion  through  seizure  of  lower  jaw,  and 
extrusion  by  means  of  pressure  in  axis  of  brim. 


over  the  face  or  in  the  mouth  of  the  fetus,  the  other  hand  press- 
ing downward  on  the  head  through  the  abdominal  wall  above  the 
pubes. 

{B')  Forceps  Extraction. — The  head  may  also  be  delivered  by 
means  of  forceps  when  it  is  delayed  within  the  pelvic  cavity.  In 
introducing  the  blades  the  body  of  the  fetus  is  directed  forward 
toward  the  pubes. 

{C)  Embryidcia. — When  the  above  methods  fail  to  deliver  the 
head,  it  is  necessary  to  reduce  the  size  of  the  latter.  This  may 
be  done  in  various  ways.  The  skull  may  be  perforated  either 
through  the  roof  of  the  mouth  or  through  the  base  of  the 
occiput.  After  the  escape  of  the  gray  matter  the  head  may 
usually  be  drawn  down. 


TEA  NS  VERSE   PRESENTA  TIONS. 


515 


6.  Mai  rotation  of  the  Head. — When  the  head  lies  in  the 
pelvis  so  that  the  occiput  is  in  the  hollow  of  the  sacrum,  or  its 
long  diameter  in  the  transverse  of  the  pelvis,  it  is  best  to  grasp 
the  head  and  trunk  and  to  rotate  them  so  that  the  occiput  is 
turned  to  the  front,  delivery  being  then  continued  in  the  manner 
already  described.  Sometimes  it  is  impossible  to  bring  about 
rotation. 

In  cases  of  breech  delivery  it  is  always  advisable  to  have  a 
skilled  assistant  at  hand  to  give  help  during  delivery  and  to  restore 
the  child,  which  is  so  frequently  asphyxiated. 

TRANSVERSE  PRESENTATIONS. 

Frequency. — Transverse  presentations  occur  in  less  than 
0.5  per  cent,  of  all  cases  of  labor. 

Causes. — These  malpresentations  may  be  found  in  the  fol- 


FlG.  230. — Axis-traction  forceps  applied  to  after-coming  head  (A.  R.  Simpson). 


lowing  conditions  :  Hydramnios,  premature  labor,  death  of  the 
fetus,  hydrocephalus,  malformations  and  monstrosities,  multiple 
pregnancy,  malformations  of  the  uterus,  tumors  of  the  uterus, 
irregular  contractions  of  the  uterus,  pelvic  and  abdominal  tumors, 
and  placenta  prjEvia. 

Varieties. — Any  portion  of  the  trunk  of  the  fetus  may 
present ;  usually  the  shoulder  is  lowermost,  and  this  variety  need 
alone  be  considered.  Sometimes  the  arm  is  prolapsed  below  the 
shoulder,  the  elbow  or  the  hand  being  lowermost.  The  long  axis 
of  the  trunk  is  very  rarely  exactly  transverse ;  it  is  usually  placed 


5i6 


ANOMALIES    OF   THE   PASSENGER. 


obliquely  in   relation  to  the  long  axis  of  the  uterus,  and  may  be 
more  or  less  bent. 

Positions. — Various  methods  are  employed  to  denominate 
shoulder  presentations,  the  acromion  process  being  used  by  some 
as  the  denominator,  the  spine  of  the  scapula  by  others.  The 
Ninth  International    Medical   Congress  adopted  a   nomenclature 


Fig.  231. — Diagram  illustrating  the  effect  of  a  malpresentation  (shoulder)  on  the 
wall  of  the  uterus  in  labor:  b,b'.  Retraction  ring,  greatly  elevated,  especially  on  the  left 
side;  a,  lower  uterine  segment,  greatly  thinned  and  stretched  over  the  head  of  the  fetus. 
The  upper  uterine  segment  is  firmly  retracted  on  the  body  of  the  fetus  (Tarnier  and 
Budin). 


as  follows  :  Scapula  laeva  anterior,  scapula  dextra  anterior,  scapula 
dextra  posterior,  scapula  laeva  posterior. 

The  following  classification  is  also  employed  : 

Dorso-anterior :    Head   on   the   right  side ;    head  on  the  left 


TRANSVERSE   PRESENTA  TIONS. 


517 


side.  Dorsoposterior :  Head  on  the  right  side ;  head  on  the 
left  side. 

Of  these  the  dorso-anterior  position,  in  which  the  head  lies  on 
the  left  side  of  the  mother,  is  the  most  frequent.  The  mechanism 
of  labor  will  be  described  in  relation  to  this  variety. 

Diagnosis. — The  shape  of  the  abdomen  differs  from  that 
found  in  the  vertex  or  breech  presentations.  The  regular  pyri- 
form  contour  of  the  uterus  is  absent,  the  latter  being  moulded 
irregularly  on  the  fetus.  The  head  usually  lies  in  an  iliac  fossa, 
sometimes  in  the  flank ;  the  breech  may  lie  in  the  opposite  fossa 
or  at  a  higher  level.     If  the  back  of  the  fetus  be  anterior,  it  is  felt 


Fig.  232. 

Fig.  232. — Overdistention  of  the  lower  uterine  segment  with  threatened  uterine 
rupture  in  a  case  of  obstructed  labor  where  the  brow  presents.  The  retraction  ring  is 
near  the  umbilicus.     The  left  round  ligament  is  tense  and  easily  palpable  (Bumm). 

Fig.  233. — Overdistention  of  the  lower  uterine  segment  in  a  case  of  obstructed  labor 
where  there  is  a  transverse  presentation.  The  retraction  ring  is  placed  obliquely  at  the 
level  of  the  umbilicus.     Both  round  ligaments  are  tense  and  easily  palpable  (Bumm). 

as  a  firm  mass  above  the  pubes  of  the  mother,  and  if  Budin's 
maneuver  of  approximating  the  fetal  poles  be  carried  out,  the  back 
is  bulged  forward  more  prominently.  If  it  be  posterior,  the  lower 
portion  of  the  abdomen  is  more  irregular,  owing  to  the  irregulari- 
ties of  the  limbs  of  the  fetus.  When  fetal  heart- sounds  are  heard 
in  a  dorso-anterior  case,  they  are  found  below  the  level  of  the 
umbilicus.  When  labor  has  been  in  progress  for  a  considerable 
tiinc,  abnormal  stretching  and  thinning  of  the  lower  uterine  seg- 


5l8  ANOMALIES   OF  THE   PASSENGER. 

merit  occur,  so  that  the  fetus  may  be  palpated  with  great  distinct- 
ness above  the  pubes,  while  at  an  abnormal  elevation  above  the 
latter  the  junction  of  the  upper  and  lower  uterine  segments  or 
retraction  ridge  may  be  felt. 

On  vaginal  examination  in  the  first  stage  of  labor  the  fornix 
lacks  the  normal  bulging  found  in  vertex  or  breech  cases.  The 
cervix  may  be  considerably  elevated  and  the  lower  uterine  seg- 
ment imperfectly  filled.  As  labor  continues  the  membranes  may 
be  pushed  downward  into  the  vagina  in  the  form  of  a  pouch  and 
the  cord  may  prolapse  inside  of  it.  When  the  fingers  can  be 
passed  within  the  cervix,  the  presenting  part  may  be  palpated. 
When  the  shoulder  presents,  the  clavicle,  humerus,  and  spine  of 
the  scapula  should  be  found  converging  toward  the  tip  of  the 
shoulder.  If  the  finger  be  passed  into  the  axilla,  the  ribs  may  be 
felt,  thus  distinguishing  that  space  from  the  groin.  When  the 
elbow  or  hand  is  prolapsed,  it  may  easily  be  distinguished,  care 
being  taken  not  to  mistake  these  parts  for  the  knee  or  foot. 

Prognosis. — Transverse  cases  allowed  to  run  a  natural  course 
are  very  dangerous  for  both  the  mother  and  the  child.  Artificial 
deliver}^  should  always  be  carried  out.  This  introduces  certain 
risks,  but  they  are  much  less  serious  than  those  attendant  upon 
natural  delivery.  The  greater  the  length  of  time  allowed  to 
elapse  before  interference,  the  graver  are  the  risks.  The  chief 
dangers  are  exhaustion  of  the  mother,  rupture  of  the  uterus 
and  other   soft   tissues,  and  sepsis. 

Varieties  of  Spontaneous  Delivery. — The  following  proc- 
esses ha\'e  been  observed  occasionally  in  transverse  cases  left  to 
themselves  : 

1.  Spontaneous  Version. — A  transverse  presentation  may 
change  to  that  of  a  head  or  breech  spontaneously,  delivery  after- 
ward taking  place  according  to  the  new  presentation.  This  is 
most  likely  to  take  place  in  multiparae  with  lax  uterine  walls  when 
the  child  is  small  and  living.  A  soft,  dead  fetus  is  not  likely  thus 
to  change  its  presentation.  Version  may  take  place  before  as  well 
as  after  rupture  of  the  membranes.  In  the  latter  case  retrac- 
tion of  the  uterus  on  the  fetus  must  be  absent,  and  it  must  not 
be  pressed  down  into  the  inlet  of  the  pelvis.  The  process  results 
from  intermittent  uterine  contractions  pressing  the  fetus  down- 
ward against  a  partly  dilated  cervix,  whose  resistance  causes  a 
displacement  of  the  presenting  part  until  the  fetus  is  partly  or 
completely  turned.  (Very  rarely  a  complete  rotation  may  occur, 
one  transverse  presentation  being  substituted  for  another.  This 
can  probably  take  place  only  when  the  fetus  is  small  and  the  liquor 
amnii  abundant.) 

2.  Spontaneous  Evolution. — This  term  is  applied  to  cases  in 
which  the  fetus  is  delivered  without  transformation  to  a  vertex  or 
breech  presentation.     Two  varieties  are  described  : 


TRANSVERSE   PRESENTA  TIONS. 


519 


{a)  Most  Frequent  (Douglas). — Uterine  contractions  force  the 
fetus  well  into  the  brim,  the  presenting  shoulder  being  pushed 
downward  to  the  sacral  segment  of  the  pelvic  floor  and  then  ro- 
tated forward  until  it  reaches  the  subpubic  angle,  the  corresponding 
arm  descending  outside  of  the  vulva.  The  body  of  the  fetus  at 
this  time  is  bent  upon  itself  somewhat  laterally,  the  head  usually 
lying  alongside  the  breech,  above  the  pelvic  brim,  the  breech 
being  posterior.  The  thorax  is  gradually  pushed  downward  over 
the  perineum,  followed  by  the  abdomen  and  lower  extremities, 
the  presenting  shoulder  during  this  process  resting  under  the 
pubes.     The  head  then  enters  the  pelvic  cavity  and  is  delivered. 


Fig.  234. — A,  B,  C,  D,  The  four  stages  of  spontaneous  evolution,  first  form  of  mechanism. 

the  occiput  usually  passing  under  the  symphysis.  This  method 
of  delivery  can  take  place  only  where  the  pelvis  is  roomy,  the 
fetus  small,  and  the  pains  strong. 

(b)  Rare  {Evolutio  Condjiplicato  Cor  pore)  (Roderer,  Klein - 
wachter). — The  fetus  is  driven  into  the  pelvis  doubled  up,  and  in 
this  position  is  forced  through  the  vulva.  It  is  thus  evident  that 
a  roomy  pelvis  and  a  small  and  easily  compressible  fetus  are 
es.sential  to  its  occurrence,  though  it  may  more  readily  occur  when 
the  fetus  is  small  and  dead.  As  the  shoulder  passes  the  outlet  the 
head  is  crowded  into  the  pelvis,  alongside  the  body  and  upper 
arm.     The  head  and  chest  are  born  after  the  presenting  shoulder 


520 


ANOMALIES    OF   THE   PASSENGER. 


and   lower 
tremities. 


arm,  being   followed   by  the   breech    and  lower  ex- 


Management. — Transverse 
cases  should  not  be  left  to  them- 
selves, artificial  interference  beine 
necessary.  When  the  diagnosis 
is  established  at  the  end  of  preg- 
nancy or  early  in  labor,  previous 
to  rupture  of  the  membranes  or 
before  the  presenting  part  is  im- 
pacted in  the  brim,  external  ver- 
sion should  be  attempted.  If 
this  fail,  the  bipolar  or  Braxton- 
Hicks  method  may  be  tried,  in 
order  to  bring  about  a  vertex 
or  breech  presentation.  If  the 
pelvis  be  normal  and  the  shoulder 
presents,  it  should  be  changed  to 
a  vertex,  if  possible.  The  labor 
may  then  be  allowed  to  continue 
naturally.  If  any  other  part  of 
the  body  than  the  shoulder  pre- 
sents, or  if  the  pelvis  be  flat,  it 
is  best  to  bring  about  a  pelvic 
presentation.  If  the  Braxton- 
Hicks  method  be  not  successful, 
the  membranes  should  be  rup- 
tured and  internal  or  podalic  ver- 
sion employed.  The  latter  procedure  should  be  attempted  only 
after  the  cervix  is  fully  dilated,  and  dilatation  should  be  accom- 
plished artificially. 


Fig.  235.— Spontaneous  evolution,  sec- 
ond and  rare  form  of  mechanism,  known 
as  birth  with  double  body  (one-sixth  nat- 
ural size,  redrawn  from  Kiistner). 


Fig.  236. — Frozen  section  of  shoulder  presentation  (Chiari).     The  distortion  and  the 
elongation  of  the  neck  are  noteworthy. 

It  is  important  to  bear  in  mind  that  in  impacted  transverse  cases 
version   may  be  a  very  dangerous  operation  if  it  be  too  long  de- 


PROLAPSE    OF   THE    ARMS  AND   LEGS.  52I 

layed,  the  risk  of  rupturing  the  greatly  stretched  and  thinned  lower 
uterine  segment  being  considerable.  It  is  impossible,  however,  to 
state  how  long  after  the  escape  of  the  amniotic  fluid  it  is  safe  to 
carry  out  version  in  any  given  case.  The  procedure  is  easier  and 
safer  the  nearer  the  time  of  the  rupture  and  the  less  the  uterus  has 
retracted  on  the  fetus.  The  operation  should  never  be  carried  out 
when  the  retraction  ridge  is  abnormally  elevated — /.  c,  is  3  in.  or 
more  above  the  level  of  the  symphysis.  In  carrying  out  version 
the  patient  should  be  deeply  anesthetized.  When  turning  is  im- 
practicable in  transverse  cases,  it  is  necessary  to  reduce  the  size  of 
the  fetus  by  decapitation,  evisceration,  or  spondylotomy.  These 
methods  will  be  described  in  another  chapter.  (See  "  Embry- 
otomy.") 

PROLAPSE  OF  THE  ARMS  AND  LEGS. 

Prolapse  of  the  limbs  may  occur  before  or  during  labor.  In 
the  latter  condition  it  may  take  place  before  or  after  rupture  of 
the  membranes.  In  some  cases  the  displacement  occurs  without 
evident  cause.  Usually  it  is  associated  with  small  fetus,  hydram- 
nios,  deformed  pelvis,  sudden  escape  of  the  liquor  amnii,  and 
attempts  at  version.  The  umbilical  cord  may  also  prolapse  in 
such  cases. 

In  Pelvic  Presentations. — One  or  both  feet  may  sometimes 
present  below  the  breech  in  pelvic  cases  and  may  be  born  first. 
Occasionally  a  hand  may  also  lie  down  close  to  the  breech.  This 
complication  does  not  interfere  with  the  delivery.  It  may  remain 
in  that  position  throughout  labor,  or  may  gradually  be  pushed 
upward  as  the  body  of  the  fetus  descends. 

In  Head  Presentations. — One  or  both  arms  may  sometimes 
lie  in  front,  behind,  or  at  the  side  of  the  head  when  it  presents  in 
labor.  The  most  serious  condition  is  the  folding  of  the  arm  across 
the  back  of  the  neck.  Most  frequently  the  arm  lies  at  the  side  of 
the  head.  As  a  result  of  the  prolapse  the  head  may  be  pushed 
aside,  so  that  a  malpresentation  is  produced.  When  the  head 
and  arm  are  jammed  in  the  brim  the  former  may  sometimes  be  in- 
dented ;  the  latter  becomes  swollen  in  its  lower  part. 

When  this  complication  is  diagnosed  early  in  labor,  an  effort 
should  be  made  to  push  the  limbs  upward,  after  the  cervix  is  fully 
dilated.  This  may  be  more  expeditiously  managed  if  the  patient 
be  placed  in  the  genupectoral  or  elevated  lithotomy  position.  If 
the  membranes  be  intact  and  the  head  not  impacted,  irritation  of 
the  arm  through  the  os  may  sometimes  cause  it  to  be  drawn 
upward  into  the  uterus.  If  the  attempt  be  not  successful,  it  is  ad- 
visable to  effect  delivery  by  version,  because  labor  may  be  much 
delayed  if  the  arm  be  allowed  to  descend  alongside  of  the  head, 
and  there  is  always  risk  that  nerves  may  be  damaged.  If  turning 
is  impossible,  forceps  should  be  used. 


522  ANOMALIES   OF   THE   PASSENGER. 

When  the  diagnosis  is  established  in  the  second  stage  of  labor, 
after  the  head  has  descended  well  into  the  brim,  it  is  usually  im- 
possible to  push  up  the  arm  without  danger  of  breaking  it.  In 
such  a  case  it  is  advisable  to  deliver  the  fetus  by  means  of  forceps. 

Very  rarely  a  foot  may  descend  alongside  of  the  head  when  the 
latter  presents.  The  line  of  treatment  is  much  the  same  as  that 
described  in  the  case  of  prolapse  of  an  arm.  Sometimes  sym- 
physiotomy or  embryulcia  is  necessary  in  cases  in  which  delivery 
is  impossible  with  forceps,  when  the  head  and  prolapsed  limb  are 
impacted  in  the  pelvis. 

In  Transverse  Presentations. — Prolapse  of  a  foot  in  trans- 
verse cases  must  be  regarded  as  favorable,  for  it  allows  version  to 
be  carried  out  easily.  When  an  arm  descends  in  a  shoulder 
presentation,  it  may  sometimes  interfere  with  the  operation  of  turn- 
ing. In  such  a  case  it  is  possible  sometimes  to  push  it  above  the 
brim,  out  of  the  way,  and  some  authorities  recommend  that  a 
piece  of  tape  be  tied  around  the  prolapsed  wrist,  in  order  that  the 
limb  may  be  prevented  from  ascending  too  high  during  the  per- 
formance of  version. 


FETAL  ANOMALIES  AND  DISEASES. 

Short  Umbilical  Cord. — The  cord  is  rarely  naturally  short, 
but  may  sometimes  be  only  a  few  inches  in  length.  Most  fre- 
quently shortness  is  accidental,  being  due  to  the  coiling  around 
the  neck,  body,  or  limbs  of  the  fetus.  The  number  of  coils  made 
by  the  cord  varies.  In  rare  instances  as  many  as  6,  7,  8,  and 
even  9  have  been  noted  ;  ordinarily  they  are  much  fewer.  There 
are  different  opinions  as  to  the  length  of  free  cord  necessary  for 
safety.  Probably  it  should  be  between  9  and  10  in.  Smellie  re- 
ported a  case  where  coilings  prevented  version  until  he  uncoiled 
the  cord.  As  a  result  of  shortening,  detachment  of  the  placenta 
may  occur  in  labor,  the  cord  may  rupture,  or  the  uterus  may  be 
inverted.  The  navel  of  the  fetus  may  be  made  to  pouch  consid- 
erably. When  it  is  coiled  around  the  fetus,  it  may  be  easily  com- 
pressed, and  so  lead  to  death  of  the  fetus.  Rupture  of  the  cord 
very  rarely  occurs.  As  regards  the  amount  of  strain  that  the 
cord  will  bear,  different  statements  are  made  ;  most  break  with  a 
weight  of  8^  pounds.  Some,  however,  will  not  bear  as  much  as 
this,  while  occasionally  one  may  be  found  that  will  resist  as  much 
as  14  or  15  pounds.  Shortness  of  the  cord  is  not  often  diagnosed 
early  in  labor.  Sometimes  there  is  pain  over  the  placental  area  dur- 
ing uterine  contractions,  and  the  area  may  be  depressed.  Labor  is 
delayed,  the  heart-sounds  of  the  fetus  may  become  irregular,  and 
unusual  recession  of  the  head  may  be  noticed  between  the  pains. 
If  separation  of  the  placenta  takes  place,  bleeding  may  be  present. 
In  some  cases  there  is  inertia  uteri.     Brickner  states  that  there  is 


FETAL   ANOMALIES  AND   DISEASES.  523 

increased  desire  to  urinate  during  the  early  part  of  the  second 
stage.  King  has  observed  a  special  desire  on  the  part  of  the 
patient  to  sit  up.  When  the  condition  is  diagnosed,  an  attempt 
should  be  made  at  the  first  feasible  opportunity  to  free  the  coils 
from  around  the  fetus,  or  to  divide  the  cord  and  promote  delivery 
with  forceps.  If  the  cord  cannot  be  ligated,  it  may  be  cut  between 
two  artery  forceps  applied  to  it.  When  the  cord  cannot  be  reached, 
the  fetus  should  be  pressed  downward.  If  the  breech  presents, 
the  labor  should  be  hastened  by  one  of  the  methods  described  in 
connection  with  that  complication. 

I/arge  Si^je  of  the  Fetus. — The  causes  of  abnormally  large 
children  are  not  definitely  known.  As  regards  the  influence  of 
heredity,  it  is  believed  that  the  paternal  is  a  more  important  factor 
than  the  maternal.  They  are  usually  males  and  are  especially 
found  in  multiparae.  Occasionally  they  are  found  in  cases  in  which 
there  is  abnormal  prolongation  of  the  period  of  pregnancy. 

Labor  is  delayed,  especially  in  the  second  stage.  The  head 
usually  becomes  markedly  moulded,  the  type  of  the  change  being 
similar  to  that  produced  by  the  passage  of  a  normal  head  through 
a  justo-minor  pelvis.  The  risk  of  rupture  of  maternal  tissues  is 
great.  In  cases  in  which  the  disproportion  between  the  head  and 
the  pelvis  is  not  too  great,  delivery  by  means  of  forceps  may  be 
carried  out.  In  bad  cases,  however,  this  procedure  is  dangerous 
and  may  lead  to  great  injury  of  the  maternal  parts.  Symphysi- 
otomy or  embryulcia  is  then  indicated. 

Smallness  of  the  Fetus. — An  abnormally  small  fetus  may 

sometimes  cause  trouble  in  labor.     It  may  lead  to  malpresenta- 

tion  or  prolapse  of  a  limb  or  of  the  cord.     Sometimes  labor  is 

so  rapid  that  the  perineum  may  be  badly  torn.     Inertia  of  the 

■  uterus  may  be  produced. 

Bxcessive  Ossification  of  the  Skull. — When  the  bones 
of  the  head  are  abnormally  hard  on  account  of  excessive  ossifica- 
tion, moulding  does  not  take  place  readily  in  labor  and  delay 
results.  The  head  may  be  arrested  either  at  the  brim  or  in  the 
pelvic  cavity.  Artificial  interference  is  usually  necessaiy,  the 
procedure  depending  upon  the  degree  of  dystocia.  Delivery  by 
forceps,  symphysiotomy,  or  embryulcia  may  be  necessary. 

In  some  cases  the  head  of  the  fetus  may  be  unusually  large, 
apart  from  hydrocephalus,  the  body  being  only  of  average  size. 

Dead  Fetus. — When  the  fetus  dies  in  the  uterus  its  tissues 
become  lax.  If  the  head  or  breech  presents,  there  may  be  no 
peculiarity  in  the  labor,  though  when  the  former  is  very  soft,  the 
ordinary  movements  may  not  take  place,  the  head  being  pushed 
directly  through  the  birth-canal,  If  there  is  a  transverse  presen- 
tation, spontaneous  delivery  may  sometimes  occur  by  one  of  the 
methods  already  described.  When  putrefactive  changes  take  place 
in  the  fetal  tissues,  leading  to  distention  of  its  body  with  gas,  the 


524  ANOMALIES    OF   THE   PASSENGER. 

labor  may  be  greatly  delayed,  and  it  is  necessary  in  such  a  case 
to  reduce  the  size  of  the  body  by  means  of  puncture.  Sometimes 
in  cases  of  labor  occurring  soon  after  death  of  the  fetus  rigor 
mortis  may  be  so  marked  as  to  delay  delivery.  (The  possibility 
of  the  occurrence  of  rigor  mortis  in  iitero  is  not  widely  known.) 
Diseases  of  the  Fetus  Causing  Enlargement. — Hydro= 
cephalus. — Enlargement  of  the  head  in  hydrocephalus  is  chiefly 
due  to  the  accumulation  of  serum  in  the  ventricles  of  the  brain, 
especially  in  the  lateral  ones.  Great  variations  are  found  in  the  con- 
dition of  the  skull.  In  slight  cases  the  bones,  fontanels,  and  sutures 
may  appear  normal,  the  bones  only  being  thinned,  little  alteration 
being  produced  in  the  brain  structure.  In  more  marked  cases 
the  brain  tissue  is  thin,  its  convolutions  being  more  or  less  flat- 
tened and  its  ventricles  enlarged.  The  size  of  the  forehead  is 
increased  relative  to  the  face,  the  frontal  bones  and  supra-orbital 
ridges  being  prominent,  and  the  fontanels  and  sutures  widened. 
In  extreme  cases  the  head  is  veiy  large,  the  greater  part  of  the 
skull  being  represented  only  by  membrane,  and  the  brain  tissue 
is  a  mere  sac,  in  which  little  or  no  trace  of  cerebrum  can  be 
'determined.  In  some  cases  irregular  centers  of  ossification  are 
found  in  the  membranous  part  of  the  skull.  Sometimes  the 
internal  changes  of  hydrocephalus  may  be  found  without  accom- 
panying alterations  in  the  skull.  The  latter  may  not  be  enlarged, 
though  the  ventricles  may  be  much  distended  and  the  brain  tissue 
much  thinned.  Occasionally  hydrocephalus  is  complicated  with 
an  extension  outward,  at  some  point,  of  the  skull  contents,  form- 
ing a  hydroencephalocele.  Spina  bifida  or  some  other  malforma- 
tion may  sometimes  be  associated  with  it.  Hydramnios  is  not 
infrequent.  The  larger  the  head,  the  greater  the  tendency  to  breech 
presentations.  In  some  cases  the  hydrocephalic  head  ruptures 
during  pregnancy,  the  membranes  shrinking  and  becoming  at- 
tached to  the  remnants  of  cerebral  tissue  at  the  base  of  the  skull 
(anencephalus  or  hemicephalus). 

Diagnosis. — In  moderate  cases  hydrocephalus  cannot  be  diag- 
nosed during  pregnancy.  Marked  enlargement  of  the  head  may 
frequently  be  palpated,  especially  when  the  breech  presents.  If, 
however,  hydramnios  be  present,  a  large  head  may  easily  be 
overlooked.  Sometimes  indentation  or  crackling  of  the  skull  may 
be  felt  through  the  abdominal  wall.  In  well-marked  cases  the  head 
has  an  elastic  consistence.  When  the  head  presents,  the  area  of 
maximum  intensity  of  the  heart-sounds  is  higher  than  normal ; 
when  the  breech  presents,  it  is  apt  to  be  lower  than  in  normal 
breech  cases.  When  the  breech  presents,  an  enlarged  head  lying 
at  the  fundus  may  be  more  easily  overlooked  than  when  the  latter 
presents.  During  labor,  if  the  head  presents,  the  cervix  may  be  felt 
to  be  very  high  during  the  first  stage,  because  the  large  size  of  the 
head  does  not  allow  it  to  descend  below  the  brim.     Dilatation  of 


FETAL   ANOMALIES  AND   DISEASES.  525 

the  cervix  may  be  considerably  delayed.  As  the  case  proceeds 
marked  bulging  is  felt  above  the  pubes  and  the  retraction  ridge  is 
elevated  abnormally  high.  When  the  fingers  can  be  introduced 
through  the  cervix,  it  may  be  possible  to  feel  the  wide  fontanels, 
wide  sutures,  or  the  membranous  character  of  the  head,  with  or 
without  areas  of  ossification.  Thin  "bones  may  crackle  under  the 
finger  like  parchment,  and  during  pains  the  membranous  head 
becomes  tense.  In  cases  in  which  the  fontanels  and  sutures  are 
not  abnormally  widened  nor  the  vertex  less  hard  than  normal, 
the  condition  of  hydrocephalus  may  easily  be  overlooked  unless 
the  head  enlargement  be  marked.  It  is  necessary  to  diagnose 
the  condition  from  enlargements  of  the  abdomen  due  to  hydram- 
nion,  twin  pregnancy,  and  tumors  ;  also  from  cases  of  pregnancy 
in  which  marked  contraction  of  the  pelvis  exists,  the  uterus  being 
abnormally  high  or  prominent. 

Prognosis. — The  outlook  for  the  mother  depends  upon  the 
degree  of  enlargement  of  the  fetal  head  and  on  the  measures  that 
are  employed  in  delivery.  She  may  become  greatly  exhausted 
from  delay  in  labor  and  rupture  of  the  uterus  may  readily  take 
place,  especially  in  the  stretched  and  thin  lower  uterine  segment. 
Keith  collected  74  cases,  in  16  of  which  the  lower  uterine  segment 
ruptured;  Poullet,  106  cases,  in  which  it  occurred  in  17.  Various 
parts  of  the  soft  passages  may  be  injured  by  long-continued 
pressure.  Sometimes  labor  is  not  much  delayed  when  the  skull 
is  largely  membranous  and  not  tense,  even  though  the  head  be 
of  considerable  size.  This  is  also  the  case  when  the  membranous 
cranial  sac  ruptures,  as  it  sometimes  does  in  labor,  especially  when 
the  breech  presents. 

Treatment. — In  every  case  in  which  marked  enlargement  of 
the  head  is  a  cause  of  danger  to  the  mother  in  delivery,  artificial 
interference  should  be  carried  out  to  effect  delivery  without  concern 
for  the  life  of  the  fetus.  When  the  head  presents,  it  should  be 
perforated  and  extraction  carried  out  by  means  of  a  cranioclast. 
In  cases  of  breech  presentation,  after  the  body  has  been  born  as 
far  as  possible,  either  the  spinal  canal  may  be  opened  and  the 
fluid  evacuated  by  an  elastic  catheter  passed  into  the  skull  through 
the  spinal  canal,  or  the  head  may  be  perforated  at  a  convenient 
point  if  it  can  be  easily  reached.  In  cases  in  which  the  head  is 
well  ossified  it  may  be  necessary  to  reduce  the  size  of  the  head  by 
breaking  the  bones. 

Hydromeningocele. — This  condition  is  an  enlargement  pro- 
duced by  a  bulging  of  the  brain  membranes  through  the  skull, 
owing  to  an  accumulation  of  serum,  especially  in  the  subarachnoid 
space. 

Enfargement  of  the  Thorax. — The  thorax  is  sometimes  en- 
larged by  serous  accumulation  in  the  pleural  cavities  (hydro- 
thorax)  or  by  pericardial  effusion.     This   may  be  associated  with 


526 


ANOMALIES    OF   THE   PASSENGER. 


ascites,  anasarca,  or  other  diseased  conditions ;  sometimes  a  new- 
growth  may  enlarge  the  chest.  The  enlargement  may  delay  labor 
to  a  greater  or  less  extent,  and  in  marked  cases  it  may  be  nec- 
essary to  puncture  the  thorax  or  reduce  its  size  in  order  to  effect 
delivery. 

Distention  of  the  Abdomen. — Ascitic  accumulation  may  cause 
marked  enlargement  of  the  abdomen,  and  is  usually  found  with 
hydrothorax  or  hydropericardium.  It  is  generally  due  to  syphilis, 
but  may  be  found  with  abdominal  tumors.  Sometimes  a  new 
growth  may  cause  great  increase  in  size.     The  d-egree  of  delay  in 


Fig.  237. — Tapping  a  hydrocephalus  through  spinal  canal  (Varnier). 

labor  varies  considerably.  In  marked  cases  it  is  necessary  to 
puncture  the  abdomen  or  to  perform  evisceration.  Distention  of 
the  kidneys  associated  with  obliteration  or  atresia  of  the  lower 
urinary  canal  is  a  rare  cause  of  abdominal  enlargement.  Dilata- 
tion of  the  bladder  is  sometimes  found  and  may  be  associated  with 
an  imperforate  urethra,  though  sometimes  it  is  not.  The  distended 
viscus  may  be  entirely  within  the  abdomen,  but  occasionally  may 
extend  downward,  bulging  the  floor  of  the  pelvis  as  well  as  pro- 
ducing an  abdominal  enlargement.  Tumors  of  the  abdominal 
viscera  are  very  rare.     Distention  of  the  uterus  and  vagina  in  con- 


FETAL   ANOMALIES  AND   DISEASES. 


527 


nection  with  atresia  of  the  latter  is  very  rarely  large  enough  to 
distend  the  abdomen. 

General  edema  of  the  body  of  the  fetus  is  sometimes  so 
marked  as  to  produce  great  delay  in  labor. 

Umbilical  or  other  hernias  may  produce  a  swelling  sufficient 
to  obstruct  delivery. 

Exomphalos  may  also  be  a  cause  of  delay. 

Hydrorrhachis. — This  is  an  accumulation  of  serum  in  a  sac 
composed  of  the  spinal  membranes  and  skin,  situated  usually  in 


Fig.  238. — Exomphalos  (A.  R.  Simpson). 


the  lower  region  of  the  back,  commonly  associated  with  spina  bifida. 
It  varies  in  size  in  different  cases,  and  may  sometimes  delay  labor. 

External  tumors,  simple  and  malignant,  may  also  obstruct 
labor.  They  may  be  found  in  any  part  of  the  body,  most  fre- 
quently in  the  region  of  the  sacrum  and  coccyx. 

General  Considerations  as  to  Treatment. — In  slip'ht  decrees  of 
obstruction  labor  may  be  shortened  by  artificial  assistance — /.  e., 
downward  pressure  through  the  fundus,  aided  by  traction  from 
below.  When  the  swelling  is  too  large  to  permit  delivery  in  this 
way,  it  must  be  reduced  in  size  by  puncture,  evisceration,  or  em- 


528  ANOMALIES   OF   THE   PASSENGER. 

biyulcia.  When  the  head  presents,  it  may  be  impossible  to  reach 
the  swelling  that  is  causing  trouble  without  first  reducing  the  head 
in  size  or  removing  it. 

Adhesion  of  Membranes. — The  causation  of  adherent  mem- 
branes is  not  fully  known.  Most  frequently  it  is  due  to  a  chronic 
endometritis  that  makes  the  inner  portion  of  the  mucosa  tougher 
than  normal,  the  attached  chorion  and  amnion  being  also  affected. 
It  is  possible  that  sometimes  the  disease  may  spread  from  the  fetal 
membranes  to  the  decidua. 

When  the  membranes  do  not  separate  from  the  lower  uterine  seg- 
ment in  the  beginning  of  labor,  the  first  stage  is  more  or  less  retarded. 
In  some  cases  the  pains  may  be  very  strong  and  yet  little  or  no 
dilatation  be  produced.    The  woman  may  become  much  exhausted. 

Treatment. — When  the  condition  is  recognized  as  a  cause  of 
delay  in  the  first  stage,  an  effort  should  be  made  to  detach  the 
membranes  from  the  lower  uterine  segment  for  an  inch  or  more 
above  the  cervix  with  a  finger.  If  this  cannot  be  satisfactorily 
accomplished,  the  cervix  should  be  partially  dilated  artificially  and 
another  attempt  made.  If  this  be  successful,  labor  may  then  be 
allowed  to  continue  naturally.  If  the  os  be  considerably  dilated 
and  the  head  be  low  in  the  pelvis,  the  membranes  may  be  rup- 
tured if  they  cannot  be  separated,  and  labor  allowed  to  proceed. 
If  the  membranes  are  ruptured  accidentally  and  the  cervix  be 
only  slightly  opened,  it  is  advisable  to  dilate  it  somewhat  artificially 
and  then  introduce  a  Champetier  de  Ribes  bag,  so  that  it  may  act 
as  a  dilator,  labor  being  allowed  to  continue.  Rapid  complete 
dilatation  and  delivery  by  artificial  means  are  necessary  only  when 
the  patient  is  exhausted  or  some  complication  exists. 

Pouciiing'  of  the  Bag  of  Membranes. — Occasionally  in  the 
first  stage  of  labor  the  bag  of  membranes  may  pouch  downward 
through  the  vagina  to  a  greater  or  less  extent,  the  amniotic  fluid 
being  forced  into  it  by  the  pains.  The  dilating  function  of  the 
bag  is  thereby  greatly  impaired  and  labor  is  consequently  delayed. 
This  condition  is  generally  found  when  the  presenting  part  does 
not  fit  well  into  the  lower  uterine  segment,  as  a  result  of  some 
complication  on  the  part  of  the  fetus,  the  bony  canal,  or  the  soft 
passages — c.  g.,  transverse  presentations,  flat  pelvis,  etc.  It  may 
develop  soon  after  the  cervix  has  begun  to  dilate  or  after  a  con- 
siderable degree  of  dilatation.  The  pouch  may  consist  both  of 
amnion  and  chorion,  or  of  the  former  alone.  The  former  is  elastic, 
and  sometimes  is  capable  of  much  distention.  The  pouch  is  forced 
lower  in  the  vagina  as  labor  proceeds,  and  may  actually  appear  at 
the  vulva.  By  some  authors  the  condition  has  been  termed 
"  hour-glass  "  constriction  of  the  membranes.  Rupture  of  the 
pouch  may  occur  at  any  time  before  the  cervix  is  fully  dilated ; 
rarely  it  may  be  preserved  during  the  second  stage.  Sometimes 
the  cord  prolapses  into  it  early  in  labor. 


FETAL   ANOMALIES  AND   DISEASES.  529 

Treatment. — Recognition  of  a  pouching  bag  of  membranes 
should  always  be  followed  by  a  careful  examination  to  determine 
the  existence  of  some  important  associated  cause  of  delay.  The 
latter  may  thereupon  require  the  chief  attention.  After  well- 
marked  pouching  has  taken  place,  the  efficiency  of  the  bag  of 
membranes  as  a  dilator  may  be  practically  disregarded.  It  may 
be  necessary  to  dilate  the  cervix  artificially,  and  the  pouch  need 
not  be  ruptured  until  this  is  completed. 

Toughness  of  the  Membranes. — It  has  already  been  noted 
that  great  variations  are  found  as  regards  the  amount  of  pressure 
under  which  the  membranes  normally  burst.  Occasionally  they 
are  excessively  tough  and  do  not  rupture  at  the  proper  time — 
viz.,  when  the  cervix  is  well  dilated.  As  a  result  of  their  per- 
sistence labor  is  somewhat  delayed.  In  some  cases  rupture  may 
not  take  place  until  the  head  has  descended  toward  the  outlet ;  in 
others,  after  a  portion  of  the  child  is  born.  Rarely  delivery  may 
take  place  without  rupture.  Sometimes  the  membranes  are  ad- 
herent as  well  as  tough. 

Treatment. — Whenever  the  cervix  is  well  dilated  and  the  mem- 
branes do  not  break  spontaneously,  they  should  be  ruptured  during 
a  pain  by  means  of  the  finger-tip,  a  dressing-forceps,  or  some 
other  suitable  instrument. 

Rupture  of  the  Umbilical  Cord. — Albert  describes  three 
varieties  of  this  accident  :  (i)  Rupture  of  individual  vessels  in  the 
cord;  (2)  rupture  of  the  whole'  cord;  (3)  avulsion  of  the  cord 
from  the  placenta  or  from  the  abdomen  of  the  fetus. 

Rupture  of  individual  vessels  is  very  rare,  and  may  be  due  to 
varix,  a  knot,  or  aberrant  vascular  arrangement  associated  with  a 
velamentous  insertion  or  with  a  succenturiate  placenta.  In  most 
cases  the  rupture  is  incidental  to  rupture  of  the  membranes. 

Rupture  of  the  cord  may  be  caused  by  artificial  deHvery,  es- 
pecially instrumental.  It  may  sometimes  occur  spontaneously. 
In  a  considerable  proportion  of  cases  it  is  due  to  delivery  while 
the  mother  is  standing. 

Avulsion  of  the  cord  from  the  abdomen  has  been  several  times 
reported.  Albert  observed  a  case  in  which  the  cord  was  torn 
from  the  placenta  during  labor ;  it  was  coiled  around  the  neck  of 
the  fetus,  and  so  made  very  short. 

Prolapsus  Funis.— The  umbilical  cord  sometimes  descends 
below  the  presenting  part  of  the  fetus.  This  may  take  place  before 
labor,  but  generally  it  occurs  only  after  the  first  stage  has  well 
advanced.  The  two  parts  of  the  prolapsed  cord  may  be  close 
together,  or  may  be  separated  by  the  head  or  other  presenting 
part  of  the  fetus.  The  prolapse  usually  occurs  in  the  depression 
on  either  .side  of  the  promontory,  rarely  elsewhere.  The  condi- 
tion is  a  serious  one  as  regards  the  life  of  the  fetus,  pressure  on 
the  cr)rd  during  labor  interfering  with  the  fetal  circulation.  Very 
34 


530  ANOMALIES    OF   THE   PASSENGER. 

rarely  may  a  living  child  be  born  Avhen  no  interference  is  car- 
ried out. 

Frequency. — Various  statistics  are  given  as  regards  the  fre- 
quency of  the  condition.  Churchill  stated  it  to  be  I  in  300  cases  ; 
Lachapelle,  i  in  380;  Jacquemier,  i  in  170.  Some  authors  have 
found  it  in  more  than  i  per  cent,  of  cases — /.  c,  Tarnier,  Engel- 
mann,  and  Michaelis. 

Etiology  and  Pathology. — The  most  important  factor  asso- 
ciated with  prolapse  of  the  cord  is  a  lack  of  accommodation  be- 
tween the  lower  uterine  segment  and  the  presenting  part  of  the 
fetus.  Normally  these  are  related  in  such  a  manner  as  to  make 
it  impossible  for  the  cord  to  fall  between  them  so  as  to  lie  beneath 
the  presenting  part. 

Various  causes  may  bring  about  a  want  of  proper  accommo- 
dation :  small  fetus ;  face,  breech,  or  transverse  presentation ; 
monstrosity  or  malformed  fetus — c.  g.,  anencephalus ;  multiple 
pregnane}' ;  presentation  of  the  head  with  a  limb ;  hydramnion, 
especialh'  associated  with  undue  mobility  of  the  fetus  ;  excessive 
length  of  the  cord  ;  velamentous  insertion  ;  low  attachment  of  the 
placenta ;  pendulous  belly  and  uterine  displacement ;  premature 
rupture  of  the  membranes  and  sudden  escape  of  the  amniotic 
fluid,  especially  if  the  woman  be  erect  or  partly  erect.  Multiparity 
is  a  favoring  condition.  Hecker  reported  28  cases  of  prolapse  of 
the  cord,  only  3  of  which  were  in  primiparae.  Deformities  of  the 
pelvis,  especially  anteroposterior  contractions  of  the  brim,  are  im- 
portant favoring  conditions.  In  primiparae  prolapse  of  the  cord  is 
almost  always  found  in  cases  of  flat  pelvis.  Litzmann  states  that 
prolapse  is  four  to  six  times  more  frequent  in  deformed  than  in 
normal  pelves.  A  contracted  brim  opposes  the  early  engagement 
of  the  presenting  part  of  the  fetus,  favors  malpresentations,  and 
opposes  the  normal  accommodation  between  the  lower  uterine 
segment  and  the  fetus.  An  abnormally  large  pelvis  may  also 
favor  prolapsus  funis. 

Tumors  and  swellings  of  the  bones  or  soft  parts  of  the  pelvis 
act  like  deformed  pelves  in  favoring  prolapse.  Excessive  move- 
ments of  the  mother  may  sometimes  play  a  part.  Interference  on 
the  part  of  the  attendant  may  be  responsible — c.  g.,  attempts  at 
version  or  forceps  application. 

Diagnosis. — Prolapse  of  the  cord  is  rarely  recognized  when  the 
cervix  is  only  partially  dilated  and  the  membranes  unruptured. 
Yet  this  is  sometimes  possible  if  digital  examination  be  made  be- 
tween pains,  the  finger  being  passed  into  the  cervical  canal  outside 
of  the  membranes.  Pulsation  may  be  felt  in  the  cord  unless  the 
fetus  be  dead  or  the  cord  be  compressed.  When  the  cervix  is 
considerably  dilated,  it  is  much  easier  to  detect  the  prolapsed 
cord ;  it  is  compressible  and  usually  mobile.  After  rupture  of 
the  membranes  the  diagnosis  is  usually  easy,  for  the  characteristic 


FETAL   ANOMALIES  AND   DISEASES.  53  I 

structure  of  the  cord  may  be  palpated  or  inspected.  It  may  be 
found  at  various  levels  in  the  vagina.  Sometimes  the  loop  is  not 
visible  and  may  be  caught  between  the  fetus  and  some  part  of  the 
bony  pelvis  above  the  level  of  the  os  externum.  This  may  cause 
death  of  the  fetus  before  the  condition  is  recognized.  Winckel  states 
that  growing  feebleness  of  the  fetal  heart-sounds  without  apparent 
reason  should  always  lead  to  the  suspicion  of  prolapsus  funis. 

It  is  to  be  remembered  that  uterine  pains  may  temporarily 
check  the  circulation  in  the  cord.  The  latter  should,  therefore, 
be  examined  chiefly  between  pains.  A  prolapsed  cord  may  some- 
times be  confounded  with  fetal  toes  or  fingers.  The  latter,  how- 
ever, have  a  definite  outline  and  may  move  when  touched,  while 
no  pulsation  can  be  felt  in  them. 

When  the  cord  has  a  velamentous  insertion  and  the  separated 
vessels  run  in  the  membranes  near  the  cervix,  the  condition  may 
be  mistaken  for  prolapse  of  the  cord. 

The  pulsation  of  maternal  vessels  in  the  fornix  may  be  mis- 
taken for  that  in  the  cord  vessels.  The  former  is,  however, 
synchronous  with  the  maternal  pulse. 

The  prolapsed  cord  may  be  mistaken  for  intestine ;  the  latter 
has  a  mesentery  and  no  pulsation. 

Prognosis. — Prolapsus  funis  in  itself  does  not  affect  the  mother. 
The  treatment  adopted  for  the  condition  may,  however,  consider- 
ably add  to  her  risks,  especially  those  due  to  hemorrhage  and 
sepsis.  The  danger  to  the  fetus  is  great,  more  than  50  per  cent, 
dying  from  asphyxiation  due  to  compression  of  the  cord.  The 
prognosis  varies  according  to  many  conditions.  When  the  head 
presents,  there  is  more  risk  of  early  compression  of  the  cord  than 
when  the  breech  or  shoulder  presents.  The  danger  to  the  fetus 
is  slighter  when  the  membranes  are  unruptured  than  after  their  rup- 
ture, and  when  the  cervix  is  only  slightly  dilated.  Primiparity  in- 
creases the  risk.  It  is  also  greater  when  the  prolapsed  loop  lies 
in  relation  to  a  part  of  the  pelvic  brim,  where  there  is  little  space 
between  it  and  the  fetus. 

Treatment. — When  the  fetus  is  dead  no  special  treatment  is 
necessary  because  of  the  prolapsed  cord,  though  interference  may 
be  advisable  for  other  reasons.  When  the  fetus  is  alive,  the  follow- 
ing measures  should  be  carried  out : 

Before  Rupture  of  the  Mejnbranes. — While  the  membranes  are 
intact  the  cord  is  to  a  great  measure  protected  by  the  liquor  amnii ; 
therefore,  care  should  be  taken  to  preserve  the  membranes  as  long 
as  possible.  First  of  all  postural  methods  should  be  employed. 
The  patient  should  be  placed  in  the  genupectoral  position  as  long 
as  pos.sible,  in  order  to  give  the  cord  a  chance  to  gravitate  toward 
the  upper  part  of  the  amniotic  cavity.  Frequently  this  maneuver 
is  successful,  the  cord  slipping  out  of  the  lower  uterine  segment, 
leaving  the  presenting  part  of  the  fetus  to  occupy  it  alone. 


532 


ANOMALIES   OF   THE   PASSENGER. 


In  hospitals  it  is  perhaps  more  convenient  to  employ  the  ex- 
treme Trendelenburg  position  instead  of  the  genupectoral.  Unless, 
however,  by  it  an  inclination  of  more  than  45  degrees  can  be  ob- 
tained, the  genupectoral  posture  should  be  employed. 

When  posture  alone  does  not  displace  the  cord,  digital  manipu- 
lations may  be  employed  between  the  pains.  These  must  be 
carried  out  very  carefully,  in  order  not  to  rupture  the  membranes, 
while  the  patient's  pelvis  is  raised.  Webster  employs  for  this 
purpose,  in  his  hospital  work,  a  table  that  allows  the  patient  to  be 
placed  in  the  elevated  lithotom}'  position,  her  shoulders  resting 
against  padded  steel  supports.  An  inclination  of  40  to  50  degrees 
may  thus  be  obtained,  and  manipulations  may  be  carried  out  very 
easily  by  the  operator,  who  stands  on  a  chair  at  the  foot  of  the 
table.     This  method  has  given  the  greatest  satisfaction. 

When  the  cord  has  been  replaced,  the  fetus  should  be  pushed 
well  down  toward  the  cervix  and  held  there  for  a  short  time. 
Sometimes  the  cord  may  be  hooked  above  a  limb  of  the  fetus  to 
prevent  another  prolapse.  The  patient  should  then  be  allowed  to 
lie  down  on  the  side  opposite  to  that  on  which  the  descent  of  the 
cord  took  place.  The  cen-ix  should  afterward  be  examined  from 
time  to  time  to  determine  whether  or  not  the  cord  has  again 
fallen.  When  these  methods  fail,  various  other  plans  maybe  tried. 
The  cervix  may  be  dilated  by  digital  ma- 
nipulations or  Barnes's  bags,  and  the  fetus 
delivered  by  \ersion  or  forceps.  It  is  ad- 
visable to  carry  out  this  procedure  in  the 
elevated  lithotomy  posture.  Recently  it 
has  been  recommended  to  introduce  a 
Champetier  de  Ribes  bag  into  the  cervix 
without  rupturing  the  membranes,  allow- 
ing labor  to  continue  spontaneously  ;  it  is 
claimed  that  the  risk  of  compression  of 
the  cord  before  rupture  of  the  membranes 
is  ver>^  slight.  W' hen  the  bag  is  expelled 
and  the  cervix  dilated,  labor  may  be 
allowed  to  continue  spontaneously  if  the 
cord  be  not  beneath  the  fetus.  If  it  be 
still  prolapsed,  version  or  forceps  may  be 
employed. 

When  the  membranes  are  ruptured  and 
the  cord  is  prolapsed,  an  effort  may  be  made  to  replace  it  by  the 
postural  methods  referred  to  above,  if  the  fetus  be  still  alive.  Usu- 
ally, however,  in  this  condition  attempts  are  made  to  replace  the 
cord  by  manipulations.  These  may  be  carried  out  by  means  of  the 
fingers  or  by  means  of  instruments.  Of  the  latter,  various  forms 
have  been  used.  The  simplest  is  a  rubber  catheter,  perforated  on 
opposite  sides  near  the  tip.     A  piece  of  tape  is  made  to  encircle 


Fig.  239. — Use  of  catheter  as 

a  porte-fillet. 


FETAL   ANOMALIES  AND   DISEASES.  533 

the  cord,  and  its  free  ends  are  passed  through  the  perforations  in 
the  end  of  the  catheter.  A  stilet  is  then  inserted  into  the  latter 
and  pushed  against  the  tape.  The  catheter  and  cord  are  then 
pushed  upward  into  the  uterus  as  far  as  possible,  and  the  stilet 
withdrawn.  The  catheter  is  left  to  be  expelled  with  the  uterine 
contents.  In  carrying  out  either  manual  or  instrumental  reposi- 
tion it  is  best  to  place  the  patient  in  the  genupectoral  or  extreme 
elevated  lithotomy  posture,  preferably  the  latter. 

After  reposition  labor  is  usually  allowed  to  continue  spon- 
taneously, though  version  or  forceps  might  be  employed  if  the 
cervix  be  well  dilated  ;  if  it  be  partially  dilated,  a  Champetier  de 
Ribes  bag  may  be  introduced,  labor  being  allowed  to  continue 
spontaneously ;  or  rapid  artificial  dilatation  may  be  carried  out. 

When  reposition  by  these  maneuvers  is  impossible  and  the  fetus 
is  alive,  delivery  should  be  carried  out  by  podalic  version  if  the 
conditions  are  favorable  ;  otherwise  forceps  should  be  used,  care 
being  taken  not  to  grasp  the  cord  between  the  blades  and  the 
head. 

If  the  cervix  be  not  sufficiently  dilated,  artificial  dilatation  should 
be  employed.  When  the  fetus  is  dead,  labor  may  continue  spon- 
taneously or  may  be  hastened,  according  to  other  indications 
present. 

Multiple  Pregnancy  in  Relation  to  I/abor. — Twin 
Cases. — Twin  labors  are  normal  in  a  considerable  percentage  of 
cases,  the  first  child  being  born,  followed  after  an  interval,  usually 
less  than  half  an  hour,  by  the  second  fetus.  Sometimes  the  in- 
terval is  much  longer  than  half  an  hour,  several  cases  having  been 
reported  in  which  it  extended  over  one  or  two  days.  Kalnikoff 
has  reported  a  case  in  which  it  lasted  for  three  days,  both  fetuses 
surviving.  As  regards  the  birth  of  the  placentae,  differences  are 
noted.  In  some  cases  the  first  child  may  be  immediately  followed 
by  its  own  placenta,  the  other  being  delivered  after  the  birth  of 
the  second  child.  Sometimes,  however,  the  second  placenta  pre- 
cedes the  second  fetus ;  usually  the  placentae  are  not  delivered 
until  both  twins  are  expelled.  In  the  case  of  a  large  single 
placenta  a  portion  may  be  torn  off  and  expelled  with  the  first 
child,  though  usually  it  does  not  appear  until  after  the  birth  of 
the  second.  Labor  may  be  delayed  in  all  its  stages  in  twin  cases,, 
especially  if  hydramnion  be  present,  the  uterine  contractions  being; 
weakened,  owing  to  the  stretching  and  thinning  of  the  wall. 
With  regard  to  hydramnion,  it  is  interesting  to  note  that  while 
this  may  affect  both  amniotic  cavities,  in  some  cases  only  one  may 
be  affected.  Spiegelberg  gives  the  following  data  representing 
the  varieties  of  presentations  found  :  Both  heads,  49  per  cent. ; 
head  and  breech,  31.7  per  cent.;  both  breeches,  8  6  per  cent.; 
head  and  transverse,  6.18  per  cent.;  breech  and  transverse,  4.14 
per  cent. ;  both  transverse,  0.35  per  cent. 


534  ANOMALIES   OF   THE   PASSENGER. 

Prognosis. — The  maternal  risks  are  considerably  greater  than 
in  cases  of  single  labors.  Owing  to  the  overdistention  of  the 
uterus,  its  contractions  are  less  effective.  If  there  be  excessive 
liquor  amnii,  there  is  an  additional  cause  of  interference,  both  with 
uterine  contractions  and  with  the  dilating  action  of  the  bag  of 
membranes,  the  uterus  being  rendered  too  spheric.  Protraction 
of  labor  may  be  found  in  all  stages.  When  the  pains  are  weak, 
labor  is  prolonged  and  the  woman's  strength  becomes  reduced. 
Albuminuria  is  Irequent,  and  eclampsia  is  more  common  than  in 
single  labors  ;  it  may  be  necessary  to  interfere  in  order  to  deliver 
the  fetuses.  In  the  third  stage  inertia  uteri  may  occur  and  may 
lead  to  postpartum  hemorrhage.  There  is  also  greater  danger  of 
septic  infection  in  the  puerperium.  If  labor  is  completely  ob- 
structed, the  patient  may  die  of  exhaustion  or  from  rupture  of  the 
uterus.  In  568  cases  collected  by  Stephenson,  15  maternal  deaths 
took  place  due  to  eclampsia,  4  to  hemorrhage,  i  to  exhaustion, 
and  7  to  sepsis.  He  found  that  convulsions  occurred  in  the  pro- 
portion of  I  in  81  cases.  Hemorrhage  was  five  times  more  fre- 
quent than  in  single  labors  ;  it  was  twice  as  frequent  during  the 
third  stage  as  postpartum,  the  placenta  being  adherent  in  a  con- 
siderable number  of  the  cases.  Retained  placenta  was  much 
more  frequent  than  in  single  labors.  Stephenson  thinks  that  the 
hemorrhage  in  twin  cases  is  largel}'  due  to  irregular  or  unequal 
uterine  retraction,  due  to  inequality  of  pressure  on  the  inner  wall 
of  the  uterus.  It  is  also  due  to  placenta  previa,  which  is  more 
frequent  than  in  single  pregnancies. 

Fetal  mortality  is  higher  than  in  single  labors ;  according  to 
Stephenson,  two  and  a  half  times  greater.  He  states  that  the 
danger  is  greater  in  the  case  of  the  second  fetus,  especially  when 
the  interval  following  the  birth  of  the  first  exceeds  half  an  hour. 
He  points  out  that  the  most  dangerous  presentation  as  regards 
the  fetus  is  that  of  the  head.  In  studying  a  series  of  cases  he 
found  that  of  the  children  lost  about  90  per  cent,  presented  by  the 
head  and  about  9  per  cent,  by  the  breech.  Among  the  footling 
and  transverse  presentations  there  was  not  a  child  lost  which  was 
alive  when  the  treatment  began.  Thus,  it  appears  that  the  more 
frequent  occurrence  of  "abnormal  "  presentations  diminishes  the 
fetal  mortality,  the  reverse  of  experience  in  single  pregnancies. 
Delivery  is  often  premature  and  the  twins  may  be  in  an  undevel- 
oped condition.  Malpresentations  and  malpositions  are  not  infre- 
quent, rendering  artificial  interference  necessary,  and  thus  increas- 
ing the  risks. 

Diagnosis. — In  the  majority  of  cases  twins  are  diagnosed  only 
after  the  birth  of  the  first  fetus  in  labor.  In  pregnancy  the  fol- 
lowing conditions  should  be  looked  for :  The  abdomen  is  larger 
than  normal,  and  it  is  more  frequently  irregular  than  in  single 
pregnancy.     Ballottement  is  usually  impossible  or  imperfect.    An 


FETAL   ANOMALIES  AND   DISEASES. 


535 


abnormal  number  of  projections  of  fetal  limbs  may  be  felt.  Two 
heads  may  be  palpated.  Two  fetal  hearts  may  be  heard  in  dif- 
ferent locations,  not  synchronously.  Frequently,  however,  the 
two  hearts  may  never  be  detected  in  pregnancy. 

Conduct  of  Labor. — When  the  condition  is  diagnosed  early  in 
labor,  the  patient  should  be  watched  carefully  throughout.  The 
abdomen  should  be  examined  from  time  to  time,  in  order  to 
determine  if  one  or  the  other  twin  becomes  displaced  so  as  to 
interfere  with  the  passage  of  the  lower  fetus.  The  lower  uterine 
segment    should    be   palpated    to    determine    whether   abnormal 


Fig.  240. — Twins — head  and  breech  (modified  from  Hunter). 

stretching  and  elevation  of  the  retraction  ridge  take  place. 
When  labor  proceeds  satisfactorily,  the  cord  should  be  tied  in 
two  places  after  the  birth  of  the  first  child.  The  abdomen  should 
be  gently  massaged  during  the  interval  between  the  expulsion  of 
the  first  and  the  second  fetus.  If  the  second  twin  presents  by  the 
head  or  breech,  the  labor  should  be  allowed  to  proceed  naturally 
if  the  interval  be  not  too  long.  There  is  a  difference  of  opinion  as 
to  how  long  a  period  may  be  allowed  to  elapse  between  the  birth 
of  the  first  and  that  of  the  second  twin.     From  Stephenson's  re- 


536 


4NOMALIES    OF   THE   PASSENGER. 


searches  it  is  certain  that  it  should  not  be  extended  beyond  half 
an  hour,  for,  though  the  mother  may  regain  her  strength,  retrac- 
tion of  the  cervix  may  occur,  leading  to  trouble  in  connection  with 
the  birth  of  the  second  child.  When  the  latter  is  transversely 
placed,  it  should  be  turned  at  once,  by  either  external  or  internal 
manipulations,  either  the  head  or  the  breech  being  made  to  present, 
most  authorities  preferring  to  deliver  by  the  breech  at  once.  F'ol- 
lowing  the  birth  of  the  second  child,  the  fundus  uteri  should  be 
massaged  by  an  assistant  until  the  third  stage  is  completed.  If 
there  should  be  partial  separation  of  the  placenta  and  loss  of 
blood,  the  uterus  should  be  emptied  by  artificial  means,  massage 
being  kept  up  afterward  and  other  methods  employed,  if  neces- 
sary, to  counteract  the  tendency  to  inertia.  In  cases  in  which  the 
birth  of  the  first  child  is  followed  by  much  loss  of  blood  or  by 
the  second  placenta,  it  is  advisable  to  interfere  at  once  and  deliver 
the  second  fetus  by  means  of  version. 


Fig.  241. — Impaction  of  heads  in  twin 
labor. 


Fig.  242. — Locking  of  heads  in  twin 
labor. 


Complex  Cases. —  i.  Labor  is  sometimes  delayed  when  both 
bags  of  membranes  bulge  downward  into  the  cervix.  In  such  a 
case,  when  dilatation  is  completed,  the  bag  of  the  leading  fetus 
should  be  ruptured. 

2.  Both  fetuses  may  tend  to  enter  the  pelvic  brim  together. 
In  such  a  case  it  is  necessaiy  to  push  one  up  and  allow  the  other 
to  engage.  If  the  head  and  breech  together  present,  the  latter 
should  be  pushed  upward. 

3.  Locking  of  the  twins.  Both  heads  or  a  head  and  a  breech 
may  become  jammed  in  the  pelvis  in  cases  where  they  present 
together.  In  such  cases  the  lower  presenting  part  should  be  de- 
livered while  the  other  part  is  pushed  upward.  Sometimes  em- 
bryulcia   of  one   fetus   is   necessar}^      In   such  an   operation   an 


FETAL   ANOMALIES  AND   DISEASES.  537 

endeavor  should  be  made  to  find  out  which  fetus  is  ahve  ;  and 
the  dead  one  should  be  destroyed,  if  possible.  Of  the  two,  the 
lowermost  fetus  is  more  likely  to  be  dead,  because  of  the  increased 
risk  of  compression  of  its  cord.  Occasionally,  where  one  child 
presents  by  the  head  and  the  other  by  the  breech,  the  latter  may 
be  born  as  far  as  the  neck  and  then  become  jammed  against  that 
of  the  second  fetus.  The  heads  may  be  related  in  dififerent  ways  ; 
thus,  the  chins  may  lock  together,  or  the  occipital  regions,  or  the 
chin  of  one  may  be  pressed  against  the  occiput  of  the  other. 
The  head  of  the  fetus  whose  body  has  been  born  usually  lies 
above  the  pelvic  brim  in  these  cases.  When  this  complication  is 
found,  an  effort  should  be  made  to  push  the  head  of  the  highest 
fetus  upward.  If  this  is  impossible,  it  is  advisable  to  perform  em- 
bryulcia  on  the  head  of  the  fetus  which  is  partly  born,  since  it  is 
almost  always  dead,  owing  to  compression  of  the  cord,  and  then 
to  deliver  the  other  fetus  by  forceps. 

4.  Twisting  of  the  umbilical  cords.  When  both  fetuses  lie  in 
one  amniotic  sac,  the  cords  may  be  twisted  around  one  another  in 
various  ways,  sometimes  even  being  knotted.  When  this  occurs 
early  in  pregnancy,  death  of  one  or  of  both  of  the  fetuses  may  occur, 
leading  to  premature  emptying  of  the  uterus.  It  may  not  take 
place,  however,  to  a  sufficient  degree  to  destroy  the  circulation  in 
one  or  both  cords,  and  the  case  may  proceed  to  full  time.  In 
labor  the  twisting  of  the  cords  may  interfere  with  the  free  passage 
of  the  twins  and  may  seriously  endanger  their  lives.  When  the 
condition  is  discovered  in  labor,  artificial  delivery  is  necessary. 

Triplets. — Triplets  are  very  rare.  The  tendency  to  premature 
labor  is  great,  and  when  this  is  the  case,  labor  may  be  simple  and 
uncomplicated.  Even  at  term  there  may  sometimes  be  no  trouble. 
The  difficulties  that  occur  are  similar  to  those  found  in  connection 
with  twin  cases.  In  458  triplet  cases  selected  by  Charbonnier  the 
head  presented  in  254,  the  breech  in  117,  and  the  body  in  57. 
This  author  has  found  that  malpresentations  and  malpositions  have 
given  trouble  in  a  very  small  number  of  cases.  The  labor  must  be 
very  carefully  attended,  especially  during  the  third  stage,  on  account 
of  the  great  liability  to  inertia  uteri  and  postpartum  hemorrhage.  In 
the  delivery  the  triplets  may  be  born  before  the  placentae,  or  each 
may  be  followed  by  its  own  ;  sometimes  one  is  born  with  its 
placenta,  followed  by  the  other  two  with  their  placentae.  Sometimes 
two  are  born,  followed  by  one  or  two  placentae,  after  which  the 
third  fetus  is  expelled,  followed  by  its  own  placenta. 

Monsters.— Anencephalus  or  Hemicephalus. — This  mon- 
strosity may  cause  difficulty  in  labor  on  account  of  the  malformed 
head,  which  does  not  easily  follow  the  normal  mechanism,  and 
being  small,  may  allow  other  parts  of  the  fetus  to  enter  the  pelvis 
along  with  it.  Indeed,  the  head  may  be  so  small  that  the  char- 
acter of  the  labor  may  early  be  determined  by  the  shoulders.     If 


538 


.ANOMALIES   OF   THE   PASSENGER. 


the  case  be  diagnosed  early  in  labor,  it  is  advisable  to  deliver  by 
version.  When  delay  occurs  in  the  second  stage,  it  is  advisable  to 
use  a  cranioclast  in  extracting  the  fetus. 

Double  Monsters. — These  are  found  in  various  combinations, 
of  which  the  following  are  the  main  types  : 

1.  Those  in  which  the  heads  are  double. 

2.  Those  in  which  the  lower  part  of  the  body  is  double. 

3.  Those  in  which  there  are  both  a  double  head  and  a  double 
body. 

Relation  to  Labor. — Monstrosities  are  very  rarely  diagnosed 
before  or  during  labor;  they  are  most  likely  to  be  mistaken  for 
twins.  Usually  they  can  be  diagnosed  only  by  the  passage  of 
the  hand  into  the  uterus.     They  may  be  delivered  without  much 


Fig.  243. — Dicephalus. 

trouble  when  small.  In  some  cases  they  may  become  jammed  or 
may  cause  a  tedious  labor.  When  artificial  interference  is  nec- 
essary, it  must  be  adapted  to  the  conditions  found.  When  there 
are  two  heads,  it  is  sometimes  possible  to  push  one  up  while  the 
other  is  allowed  to  engage.  Version  is  sometimes  necessary  to 
delivery ;  occasionally  the  forceps  may  be  applied  with  advan- 
tage to  the  advancing  head.  In  some  cases  it  is  necessary  to 
break  up  the  monster.  Indeed,  some  advise  that  craniotomy 
should  be  performed  in  all  cases. 


PLACENTA    PRyEVIA.  539 

CHAPTER   V. 
COMPLEX  LABOR. 

UTERINE  HEMORRHAGE  BEFORE  THE  EXPULSION  OF  THE 
CHILD,  ASSOCIATED  WITH  THE  SEPARATION  OF  A  NOR- 
MALLY OR  ABNORMALLY  PLACED  PLACENTA. 

Uterine  hemorrhage  in  the  early  months  of  gestation  has 
already  been  considered  in  connection  with  abortion.  In  the 
present  connection  the  subject  is  considered  both  in  regard  to  full- 
time  labor  and  to  advanced  pregnancy. 

PLACENTA    PRAEVIA. 

By  this  term  is  meant  the  attachment  of  the  placenta  to  that 
portion  of  the  uterine  wall  which  forms  the  lower  uterine  segment 
in  labor.  In  describing  the  anatomy  of  pregnancy  and  labor  I 
have  pointed  out  that  the  lower  uterine  segment  has  no  definite 
upper  boundary  in  pregnancy,  but  that  the  latter  is  determined  by 
the  retraction  ridge,  which  develops  only  after  labor  begins.  The 
exact  anlage  of  this  ridge  in  the  wall  of  the  pregnant  uterus  is  not 
accurately  known,  variations  being  found  in  its  position.  More- 
over, while  its  distance  above  the  os  externum  has  been  measured 
in  Chiari's,  Braune's.  and  Barbour  and  Webster's  second-stage 
specimens  in  which  the  cervix  is  fully  dilated,  its  distance  above 
the  OS  internum  is  not  precisely  known,  since  the  latter  cannot  be 
accurately  determined.  The  information  afforded  by  the  frozen 
sections  of  first-stage  cases  is  not  sufficient  to  establish  the  anlage 
of  the  retraction  ring.  It  can  be  approximately  placed  at  a  dis- 
tance if  to  2\  in.  above  the  os  internum,  being  longer  posteriorly 
than  anteriorly ;  it  varies  somewhat  in  position  in  different  cases. 
In  examining  specimens  of  the  pregnant  uterus  it  may  be  impos- 
sible in  some  cases  to  state  whether  or  not  the  placenta  should  be 
considered  as  praevia. 

The  hemorrhage  that  occurs  as  the  result  of  placenta  praevia 
was  termed  unavoidable  by  Rigby,  and  is  so  named  at  the  present 
day.  He  employed  it  in  distinction  to  the  term  accidental,  applied 
to  that  form  of  hemorrhage  which  results  from  separation  of  a 
placenta  normally  situated — i.  e.,  above  the  retraction  ridge. 

Frequency. — Statistics  as  to  the  frequency  of  placenta  praevia 
vary  considerably.  In  so  far  as  it  causes  hemorrhage  in  advanced 
pregnancy  or  labor,  its  frequency  is  generally  stated  to  be  on  the 
average  I  in  lOOO  cases.  Miiller's  statistics  are  i  in  1078; 
Klein's,  I  in  760;   Lomer's,  i  in  723;  Veit's,  i  in  2000. 

In  maternities,  where  a  larger  percentage  of  these  cases  occur, 
Tarnicr  and   Budin   state  that  the  frequency  is  less  than  I  in  300. 


540 


COMPLEX  LABOR. 


In  the  Boston  Lying-in  Hospital  in  twenty  years  Townsend  found 
it  to  be  about  i  in  240.  Boss  reports  it  in  Breslau  as  i  in  1 30 ; 
Amadei  and  Ferri,  i  in  52.9,  or  1.89  per  cent. 

If  the  number  of  instances  in  which  placenta  praevia  causes 
abortion  in  early  pregnancy  be  taken  into  consideration,  as  well 
as  those  slightly  marked  cases  in  which  little  or  no  bleeding  takes 
place,  the  condition  must  be  regarded  as  occurring  more  fre- 
quently than  I  in  1000  in  ordinary  practice;  it  is  impossible, 
however,  to  give  an  accurate  estimate.  It  is  much  more  frequent 
in  multiparas  than  in  primiparas.  This  was  first  pointed  out  by 
Sir  J.  Y.  Simpson,  who  collected  81  cases,  of  which  73  were  mul- 
tiparae.  Amadei  and  Ferri  report  97  cases,  of  which  86  were 
multiparas.  Reed  states  that  placenta  prsevia  is  three  times  as 
frequent  after  thirty  as  before. 

Varieties. — The  following  classification  is  usually  employed  : 
Complete  or  central,  when  the  os  internum  is  completely  covered 

by  the  placenta ;  partial,  when 
the  greater  portion  lies  on  one 
side  of  the  os,  the  remainder 
covering  the  os  ;  marginal,  when 
the  margin  of  the  placenta  crosses 
the  OS  ;  lateral,  when  the  lower 
part  of  the  placenta  lies  in  the 
lower  uterine  segment,  being  near 
the  OS  only  when  dilatation  oc- 
curs. These  terms  are  often 
loosely  employed,  the  os  being 
considered  as  undilated,  partially 
dilated,  or  fully  dilated.  It  is 
evident  that  an  individual  case 
might  be  described  as  belonging 
to  more  than  one  variety,  accord- 
ing to  the  condition  of  the  cervix. 
The  above  classification  implies 
an  undilated  cervix.  Some  au- 
thorities use  only  two  terms,  com- 
plete and  partial.  As  regards  the 
relative  frequency  of  these  varia- 
tions, Lomer,  in  136  cases  of  pla- 
centa prsevia,  found  that  only  26 
were  complete  ;  Townsend,  in  28  cases,  found  5  ;  Demelin,  in  302 
cases,  found  28  ;  Boss,  in  133  cases,  found  37;  Amadei  and  Ferri 
found  I  in  24  cases. 

From  the  developmental  standpoint  three  varieties  maybe  noted : 

1.  That  in  which  the  portion  of  the  placenta  in  relation  to  the 
lower  uterine  segment  is  entirely  serotinal. 

2.  That  in  which  it  is  reflexal. 


Fig.  244. — Partial  placenta  praevia, 
vertex  presentation :  the  os  beginning 
to  dilate  ( Lusk). 


PLACENTA   PK^EVIA.  54 1 

3.  That  in  which  it  is  both  serotinal  and  reflexal. 

Ktiology. — The  majority  of  the  earUest  obstetric  writers — 
/.  e.,  Mauriceau,  Astruc,  Dionis,  Daventer,  Pugh,  and  others — held 
that  the  ovum  in  cases  of  placenta  praevia  had  not  developed  from 
the  beginning  in  the  lowest  part  of  the  uterine  cavity,  but  that  it 
had  originally  been  attached  in  the  upper  normal  zone,  from 
which  it  had  become  accidentally  loosened,  falling  by  its  own 
weight  to  the  lower  zone,  where  it  continued  its  development. 
Portal  appears  to  have  been  the  first  who  described  placenta 
praevia  as  having  arisen  from  the  implantation  of  the  ovum  in  the 
lower  part  of  the  uterus  from  the  beginning.  This  view  was  held 
by  several  other  authorities — /.  e.,  Roederer,  Levret,  and  SmeUie^ 
and  it  was  mainly  due  to  the  writings  of  the  last  of  these  that  it 
became  generally  accepted. 

In  1888  Hofmeier,  at  the  German  Gynecologic  Congress  in 
Halle,  advanced  the  opinion  that  placenta  prsevia  is  due  to  the 
development  of  villi  of  the  chorion  laeve,  which  are  attached  in 
the  early  stages  of  gestation  to  the  decidua  reflexa,  and  which 
normally  atrophy.  He  believes  that  as  the  latter  becomes  ab- 
sorbed or  blended  with  the  vera  these  villi  remain  functional, 
forming  the  lower  portion  of  the  placenta,  continuous  with  the 
serotinal  or  true  placenta.  In  1890  Kaltenbach  adopted  the  same 
view  and  proposed  the  definition  that  the  placenta  is  prsevia  when 
attached  over  the  lower  pole  of  the  reflexa.  This  view  has  been 
enthusiastically  received  in  many  quarters,  and  several  specimens 
have  been  exhibited  in  recent  years,  clearly  demonstrating  the 
reflexal  placenta.  Such  an  one  is  that  represented  by  me  in 
Fig.  56. 

That  placenta  praevia  is  always  formed  in  this  way  cannot, 
however,  be  held.  Another  specimen,  represented  in  Figs.  245 
and  246,  proves  conclusively  that  the  condition  may  arise  from 
the  development  of  a  chorion  frondosum  developing  normally  in 
relation  to  a  decidua  serotina,  situated  from  the  beginning  in  the 
lower  portion  of  the  uterine  body.  Gottschalk,  in  1897,  described 
a  specimen  demonstrating  the  same  fact.  Kaltenbach  has  stated 
that  a  primary  implantation  of  the  ovum  near  the  os  internum  is 
unHkely  because  of  the  nearness  of  the  cervical  canal,  down 
which  the  ovum  would  probably  pass.  This  speculation  is  of  no 
value  in  view  of  the  demonstration  of  such  specimens  as  Gott- 
schalk's  and  mine. 

In  some  cases  placenta  praevia  may  be  due  to  a  combination 
of  the  conditions  mentioned — viz.,  primary  low  implantation  of 
the  ovum  and  persistent  chorionic  development  on  the  reflexa. 
In  my  second  specimen  both  conditions  exist,  though  the  amount 
of  placental  tissue  attached  to  the  reflexa  is  very  small. 

The  explanation  of  primary  low  implantation  of  the  ovum  is 
a  matter  of  pure  speculation.    Whether  the  ovum  is  carried  down 


54-2  ^  COMPLEX  LABOR. 

by  the  action  of  the  cilia  on  the  cells  of  the  uterine  mucosa,  by 
the  movement  of  fluid  in  the  cavity,  or  by  mechanical  displace- 
ment, we  do  not  know.  Nor  are  we  able  to  say  anything  regard- 
ing the  possibility  that  the  ovum  may  have  some  power  of  move- 
ment in  itself  or  exercise  some  selective  function. 

One  simple  yet  feasible  reason  may  be  advanced  to  explain  a 
low  primary  implantation  of  the  ovum — viz.,  fertilization  of  an 
ovum  by  spermatozoa  in  the  lower  part  of  the  uterine  cavity.  Of 
course,  there  is  at  the  present  time  a  widespread  belief  that  this 
process  generally  takes  place  in  the  Fallopian  tube,  but  no  one 
can  presume  to  say  in  what  percentage  of  cases  this  is  found,  nor 
place  any  limit  upon  the  range  of  its  occurrence.  It  is  not  at  all 
unlikely,  therefore,  that  occasionally  the  ovum  and  spermatozoa 
may  meet  in  the  lower  part  of  the  uterus,  followed  by  low  im- 
plantation and  development. 

The  explanation  of  placenta  praevia  resulting  from  a  reflexal 
placental  formation  may  be  undertaken  with  more  facts  and  less 
speculation.  Hubert  Peters  has  described  the  earliest  stage  in 
the  formation  of  the  human  reflexa.  He  has  shown  that  the 
young  ovum,  on  becoming  attached  to  the  uterine  mucosa,  sinks 
rapidly  into  the  compact  layer,  excavating  laterally  as  well  as 
deeply.  The  overhanging  portion  of  the  compacta  forms  the 
reflexa,  the  gap  through  which  the  ovum  has  entered  being 
closed  by  the  organization  of  blood-clot.  The  thickness  of  the 
reflexa  must  depend  to  a  considerable  extent  upon  the  amount  of 
excavation  caused  by  the  ovum,  though  it  also  varies  according 
to  the  thickness  of  the  mucosa  at  the  site  of  embedding  and  ac- 
cording to  the  degree  of  decidual  development  taking  place.  The 
basal  part  of  the  reflexa  is  always  the  thickest  part,  and  is  similar 
to  the  neighboring  compact  layer  of  the  serotina  in  early  preg- 
nancy. The  layer  thins  toward  the  outer  polar  part,  showing  less 
vascularization  and  tending  to  undergo  early  degenerative  changes. 
Blood-extravasation  is  frequent  in  the  substance  of  the  reflexa, 
coagulation-necrosis  in  the  decidual  tissue  constantly  occurs,  and 
blood-channels  become  closed. 

In  the  earliest  changes  that  take  place  in  the  outer  epiblastic 
covering  of  the  ovum,  no  distinction  can  be  traced  between  the 
portion  related  to  the  reflexa  and  that  related  to  the  serotina ; 
neither  is  there  any  distinction  between  the  villi  during  the  first 
few  weeks  of  gestation.  Gradually  differences  are  noted,  the  villi 
of  the  chorion  laeve  (those  in  relation  to  the  reflexa)  showing  less 
growth-tendency  the  farther  they  are  from  the  serotina.  As 
pregnancy  advances  retrogressive  and  degenerative  changes  occur, 
fibrin  formation  takes  place  in  the  maternal  blood  between  the 
villi  and  on  the  inner  surface  of  the  reflexa. 

There  has  been  some  difference  of  opinion  as  to  the  relation- 
ships between  the  degenerative  changes  in  the  reflexa  and  those 


rL  A  CENTA    PRyK  VIA. 


543 


in  the  villi  related  to  it.  There  can,  however,  be  very  little  doubt 
that  the  degenerated  condition  of  the  reflexa  is  the  occasion  of 
retrogression  in  the  villi  attached  to  it.  Of  these  villi,  those 
nearest  the  serotina  become  most  developed  and  are  the  last  to 
degenerate.  This  is  due  to  the  fact  that  the  basal  reflexa  to 
which  they  are  attached  is  most  developed  and  degenerates  most 
slowly.  In  certain  cases  in  which  there  are  abnormal  growth  and 
continuance  of  a  portion  of  the  chorion  laeve  forming  the  so- 
called  reflexal  placenta,  continuous  with  the  serotinal  placenta, 
there  seems  to  be  an  exceptional  development  of  the  decidua 
reflexa,  especially   near  the   serotina,  the   degenerative   changes 


Fig.  245. — Vertical  mesial  section  of  uterus  at  end  of  third  month  of  pregnancy. 
Right  half.  The  specimen  is  in  the  author's  collection  in  Rush  Medical  College, 
Chicago.  It  is  somewhat  elongated  vertically  and  narrowed  transversely  by  its  sus- 
pension in  a  jar.  The  lower  part  of  the  cervix  has  been  cut  away.  The  decidua 
reflexa  is  a  thin  membrane  that  has  fallen  somewhat  inward  and  rests  on  the  embryo. 
The  placenta  is  situated  on  the  anterior  uterine  wall,  which  it  mostly  covers.  Its  upper 
end  is  at  the  fundus ;  its  lower  end  at  the  os  internum,  where  it  is  attached  for  a  length 
of  1.3  cm.  to  the  reflexa.  Blood  hes  between  the  reflexa  and  the  os  internum  :  a.  Em- 
bryo ;  b,  serotinal  placenta;  c,  slight  extension  of  placenta  on  decidua  reflexa;  </, 
decidua  reflexa,  which  has  fallen  inward  against  the  embryo  ;  e,  part  of  the  cervix  ;  f, 
wall  of  uterine  body. 

being  much  less  marked  than  in  ordinary  cases.  As  a  result  of 
the  gradual  thinning  of  the  reflexa,  together  with  the  intrinsic 
necrotic  changes  that  I  have  described,  rupture  of  its  substance 
with  consequent  hemorrhage  may  easily  be  brought  about.     One 


544 


COMPLEX  LABOR. 


of  my  specimens  (Fig.  246)  illustrates  this  condition ;  the  ex- 
travasated  blood  between  the  reflexa  and  the  os  internum  is  due 
to  rupture  of  a  small  portion  of  the  reflexa  to  which  well-marked 
chorionic  villi  are  attached. 

If  there  be  no  disturbance  of  gestation  in  the  early  months,  there 
may  be  in  the  later.  These  variations  probably  depend  mainly 
upon  the  degree  of  preservation  of  that  part  of  the  reflexa  to 
which  the  placenta  is  attached  and  the  amount  of  blending  with 
the  vera  that  takes  place.     It  has  long  been  held  that  in  normal 


Fig.  246. — Left  half  of  specimen  described  in  Fig.  245.  The  inferior  edge  of  the 
placenta  (reilexal  portion)  and  the  neighboring  decidua  reflexa  are  considerably  torn 
by  blood-extravasation,  which  has  formed  an  accumulation  between  the  reflexa  and 
vera  on  the  left  side,  resembling  a  small  hen's  egg, 'somewhat  flattened:  a,  Amniotic 
cavity  ;  b,  serotinal  placenta ;  c,  lower  edge  of  placenta,  torn  by  blood-extravasation  ; 
d,  lower  portion  of  blood-clot,  lying  between  reflexa  and  vera ;  e,  blood-clot  bulging 
the  reflexa  and  membranes  inward  ;  /",  anterior  uterine  wall. 

pregnancy  the  reflexa  gradually  merges  with  the  vera,  so  that  it 
forms  the  inner  layer  of  the  latter  during  the  advanced  months. 
The  Avork  of  Minot,  E.  Frankel,  and  myself  has  shown  that 
blending  occurs  only  to  a  partial  extent  and  in  varying  degrees. 
During  the  fourth  month  I  have  sometimes  found  the  reflexa 
partly  distinguishable  as  a  continuous  thin  hyaline  membrane  lying 
in  contact  with  the  vera,  but  more  frequently  as  a  broken  layer, 
parts  of  it  being  absent,  the  remains  of  the  degenerated  chorion 
laeve  at  these  intervals  lying  against  the  vera.     During  the  fifth 


PLACENTA    PRMVIA.  545 

month  fewer  traces  of  the  reflexa  are  usually  found.  During  the 
later  months  small  portions  may  sometimes  be  noticed  as  patches 
of  fibrin  containing  degenerated  villi. 

When  there  is  no  early  interruption  of  gestation  in  the  con- 
dition of  reflexal  placenta,  the  occurrence  of  hemorrhage  in  the 
later  months  is  probably  mainly  determined  by  the  state  of  that 
part  of  the  reflexa  to  which  the  villi  are  attached  and  by  the  extent 
and  nature  of  the  union  that  may  have  taken  place  between  it  and 
the  decidua  vera.  If  there  be  firm  union  hemorrhage  is  less  likely 
to  occur  during  pregnancy  than  if  it  be  absent.  When  a  case 
progresses  to  the  seventh  or  eighth  month,  hemorrhage  then  taking 
place,  the  explanation  probably  is  that  there  has  been  an  unusually 
thick  or  strong  reflexa ;  that  degeneration  has  taken  place  very 
slowly  or  to  a  slight  extent,  and  that  the  mechanical  stretching 
that  the  membrane  normally  undergoes  has  not  been  able  to  pro- 
duce an  earlier  rupture  of  its  substance.  If  a  case  of  reflexal 
placenta  continues  to  full  term,  it  is  probably  one  in  which  firm 
blending  has  taken  place  between  the  reflexa  and  vera.  The  great 
majority  of  cases  of  placenta  praevia  that  go  to  term  are  probably 
those  in  which  there  has  not  been  a  reflexal  placenta,  but  in  which 
the  ovum  has  been  implanted  low  in  the  uterus  from  the  begin- 
ning. In  these  cases  hemorrhage  need  not  be  expected  until  canali- 
zation of  the  cervix  and  lower  uterine  segment  has  begun,  producing 
that  disproportion  between  the  placenta  and  the  area  of  its  attach- 
ment on  the  uterus  that  inevitably  results  in  the  loss  of  blood. 

Bayer  and  others  have  tried  to  explain  the  hemorrhage  occur- 
ring in  placenta  prsevia  cases  previous  to  full  term  by  the  old  view 
that  the  upper  portion  of  the  cervix  was  taken  up  to  form  part  of 
the  lower  uterine  segment  during  the  late  months,  in  this  way 
bringing  about  a  separation  between  the  uterus  and  placenta. 
This  explanation  no  longer  can  claim  attention,  since  anatomic  in- 
vestigations have  abundantly  proved  that  the  cervix  does  not 
enter  into  the  formation  of  the  lower  uterine  segment  during 
pregnancy. 

Another  explanation  has  been  put  forward  to  the  effect  that  the 
diameter  of  the  lower  segment  of  the  uterus  increases  during  the 
last  months  of  gestation,  and  that  this  increase  in  area  leads  to  a 
separation  of  the  placenta.  Anatomic  facts  also  disprove  this 
view.  The  full  capacity  of  the  lower  uterine  segment  is  ordi- 
narily attained  by  the  fifth  month.  Thereafter  the  great  increase 
in  the  uterus  is  almost  entirely  due  to  a  development  of  the  upper 
portion.  Slight  dilatation  of  the  cervix  may  take  place  during 
the  last  weeks  of  gestation  in  multiparae.  This  might,  in  a  case 
of  placenta  prsevia,  cause  some  separation  in  the  region  of  the  os 
internum. 

Summary. —  i.  Three  different  sets  of  conditions  explain  the 
occurrence  of  placenta  praevia  : 

35 


546 


COMPLEX  LABOR. 


{a)  Low  implantation  of  the  ovum. 

{b)  Development  of  chorionic  villi  on  the  decidua  reflexa,  form- 
ing a  reflexal  placenta. 

(r)  Low  implantation  of  the  ovum  together  with  a  reflexal  pla- 
centa. 

2.  Reflexal  placenta  praevia  is  probably  a  frequent  (though 
generally  unrecognized)   cause  of  abortion  and   miscarriage,  the 


Fig.  247.— Partial  placenta  praevia  (Ahlfeld). 

degenerated  .reflexa    becoming    thinned     and    torn,    leading    to 
hemorrhage. 

3.  Cases  of  placenta  praevia  that  reach  full  time  are  probably 
in  most  instances  those  in  which  a  reflexal  placenta  has  not  been 
present,  but  in  which  the  ovum  has  been  implanted  low  in  the 
uterus,  the  serotina  thereby  lying  partly  or  entirely  in  the  lower 
uterine  segment. 

4.  Cases  of  reflexal  placenta  praevia  in  which  the  gestation  is 
not  interrupted  until  the  end  of  pregnancy  are  probably  those  in 
which  the  late  appearance  of  hemorrhage  is  due  to  unusual  strength 


PLACENTA    PRyEVIA.  547 

and  thickness  of  the  reflexa  and  to  the  slow  advance  of  degenera- 
tive changes  in  it.  Persistence  of  a  reflexal  placenta  praevia  to 
full  term  is  probably  a  very  rare  occurrence,  and  is  explained  by 
non-rupture  of  the  reflexa  because  of  the  above-mentioned  char- 
acteristics, or  by  firm  blending  of  the  reflexa  with  the  vera. 
Hemorrhage  occurring  in  the  late  months  of  pregnancy,  when  the 
placenta  praevia  is  not  reflexal  in  origin,  is  probably  generally  due 
to  some  degree  of  dilatation  of  the  cervix  that  may  or  may  not  be 
the  earliest  sign  of  premature  labor.  The  onset  of  labor,  with 
consequent  increasing  dilatation  of  the  cervix  and  lower  uterine 
segment,  necessitates  further  disproportion  between  the  placenta 
and  the  site  of  its  attachment,  and  increasing  separation. 

5.  In  all  conditions  of  placenta  praevia  hemorrhage  may  result 
from  various  causes  that  are  entirely  independent  of  the  position 
of  the  placenta,  which  may  also  .be  effective  when  the  placenta  is 
normally  situated. 

6.  In  a  considerable  proportion  of  cases  in  which  uterine 
hemorrhage  occurs  in  advanced  pregnancy,  where  the  diagnosis 
of  "  accidental  hemorrhage  "  is  made,  placenta  praevia  of  reflexal 
origin  is  probably  present.  Unless  the  placenta  be  within  easy 
reach  of  the  examining  finger,  a  careless  observer  might  easily 
conclude  that  its  attachment  is  normal.  A  thorough  study  of  the 
shed  placenta  and  membranes  is  necessary  to  establish  the  true 
nature  of  these  cases,  though  it  may  sometimes  be  inconclusive 
because  of  disturbed  and  altered  relationships. 

Condition  of  the  Placenta. — The  placenta  is  often  abnormal. 
In  all  probability  the  most  marked  variations  are  found  when  it  is 
largely  reflexal  in  origin,  the  reason  for  which  has  already  been 
given.  It  may  be  much  spread  out  and  thinned,  sometimes  cover- 
ing a  large  area.  Some  parts  may  be  well  developed  ;  others  may 
be  much  degenerated,  the  villi  being  largely  destroyed  and  sur- 
rounded with  fibrin.  Sometimes  it  may  have  a  patchy  appear- 
ance. Detached  portions  {^placenta  S7iccentiiriatd)  may  be  found. 
The  outline  may  vary  greatly,  being  round,  oval,  reniform,  and 
lobed.  The  cord  usually  has  an  eccentric  attachment.  Some- 
times it  enters  the  placenta  at  the  border  or  has  a  velamentous 
insertion.  According  to  Kilian,  the  placenta  is  more  frequently 
situated  posteriorly  than  anteriorly.  Miiller  states  that  when 
there  is  a  partial  placenta  praevia,  the  lower  edge  extends  toward 
the  right  more  frequently  than  to  the  left.  It  is  frequently 
adherent. 

Source  of  Bleeding. — From  what  has  been  stated,  it  is  evi- 
dent that  in  some  cases  blood  may  escape  from  torn  vessels  in 
the  decidua  reflexa ;  in  other  cases  from  those  in  the  serotina, 
owing  to  the  separation  of  the  placenta.  As  well,  blood  may 
pour  from  the  intervillous  space  that  may  be  opened,  though  such 
hemorrhage  tends  to  be  checked  by  a  massing  of  the  villi  together 


548 


COMPLEX  LABOR. 


and  by  coagulation  of  the  blood  on  their  surface.  The  so-called 
circular  sinus  or  sinus  of  Meckel  is  often  noted  as  a  source  of  bleed- 
ing, and  it  indeed  may  be,  if  it  be  torn.  This  blood-space  should 
not,  however,  be  termed  a  sinus,  as  it  is  merely  the  outer  portion 
of  the  intervillous  space  at  the  edge  of  the  placenta,  where  few 


Fig.  248. — Central  placenta  prsevia,  the  os  partly  dilated  (Hunter). 

vilH  exist.     It  never  exists  as  a  continuous  canal  around  the  pla- 
centa, but  is  interrupted  at  irregular  intervals  by  abundant  villi. 

Symptoms. — Placenta  praevia  may  exist  for  varying  periods 
without  causing  any  symptoms.  In  many  cases  these  may  de- 
velop in  the  early  months,  and  are  those  described  in  connection 
with  abortion,  hemorrhage  from   the  uterus  being  the  first  and 


PLACENTA    PR.^EVIA.  549 

chief  occurrence.  After  the  early  months  hemorrhage  may  occur 
at  any  time.  In  the  majority  of  cases  in  which  the  condition  con- 
tinues to  an  advanced  period  it  usually  takes  place  during  the 
eighth  or  ninth  month.  It  usually  appears  suddenly  during  the 
day  or  night,  and  the  first  flow  may  be  abundant  or  scanty.  It 
does  not  ordinarily  follow  any  exciting  cause,  though  sometimes 
it  may  be  associated  with  some  form  of  physical  exertion,  though 
the  association  may  have  nothing  whatever  to  do  with  the  hemor- 
rhage. (Detachment  of  a  placenta  praevia  may  also  be  brought 
about  by  any  of  the  conditions  that  may  separate  a  placenta 
situated  in  the  upper  uterine  segment.) 

In  some  cases  the  hemorrhage  may  continue  so  excessive  from 
the  onset  that  the  woman  is  reduced  to  a  dangerous  condition  of 
anemia,  exhibiting  marked  pallor,  syncope,  dimness  of  vision, 
jactitation,  irregular  sighing  respirations,  etc.  Frequently  after 
the  first  bleeding  there  is  an  interval  of  hours  or  days,  followed  by 
another  discharge,  and  this  may  be  repeated.  As  the  case  pro- 
gresses the  intervals  become  shorter.  Rarely  there  is  a  con- 
tinuous dribbling  of  blood.  During  labor  the  escape  of  blood  from 
the  opened  sinuses  is  usually  most  marked  as  the  pains  pass 
away.  During  active  uterine  contractions  the  ovum  compresses 
the  placenta  against  the  lower  segment,  and  so  tends  to  prevent 
further  escape  from  the  vessels.  At  the  same  time,  blood  that 
has  been  poured  out  is  forced  through  the  cervix  by  these  pains. 
The  common  statement  that  in  placenta  praevia  the  hemorrhage 
occurs  mainly  during  the  pains  is  correct  only  as  applied  to  a 
limited  number  of  cases. 

Physical  Signs. — Rarely  placenta  praevia  may  be  detected 
by  abdominal  palpation  when  it  is  situated  anteriorly  in  the  uterus. 
The  maternal  souffle  may  be  heard  over  the  lower  portion  of  the 
uterus ;  the  edge  of  the  placenta  may  sometimes  be  felt  as  a 
ridge ;  the  fetal  parts  are  felt  very  indistinctly  within  the  area  of 
the  placenta. 

On  vaginal  examination,  when  the  placenta  covers  the  lower 
segment  entirely,  ballottement  may  not  be  obtained  or  only  indis- 
tinctly, and  the  fetal  parts  cannot  be  palpated.  The  tissues  pal- 
pated through  the  anterior  fornix  have  a  boggy  feeling.  When 
the  placenta  praevia  is  complete,  the  vaginal  signs  are  similar 
though  more  extensive,  being  the  same  in  the  posterior  as  in  the 
anterior  fornix.  When  the  placenta  is  situated  on  the  posterior 
wall,  its  anterior  edge  being  marginal,  its  presence  is  rarely  de- 
tected on  vaginal  examination. 

When  the  cervix  is  dilated  sufficiently  to  admit  a  finger,  the 
placenta  may  be  felt  as  a  stringy  mass  when  it  is  complete.  When 
it  is  lateral  or  marginal,  the  edge  may  usually  be  palpated.  On 
rectal  examination,  when  the  lower  uterine  segment  posteriorly  is 
partly  occupied  by  the  placenta,  its  edge  may  be  felt  as  a  ridge. 


5 so  ^  COMPLEX  LABOR. 

When  it  is  entirely  occupied,  a  boggy  thickness  is  made  out, 
palpation  of  the  fetus  is  indistinct,  and  ballottement  is  difficult  or 
impossible. 

It  must  be  distinctly  understood  that  this  examination  is  rarely 
necessary.  If  it  be  employed  as  a  routine,  the  practitioner  is 
certain  to  add  to  the  risks  of  infection,  owing  to  carelessness  in 
cleansing  the  fingers  before  using  them  again  in  the  genital  passage. 
When  a  rectal  examination  is  made,  it  is  always  advisable  to  wear 
a  rubber  glove. 

Prognosis. — Placenta  praevia  must  be  regarded  as  a  serious 
compHcation  of  pregnancy  and  labor,  for  both  the  mother  and  the 
child.  It  is  usually  stated  that  the  risks  are  greater  the  larger 
the  area  of  the  lower  uterine  segment  covered  by  placenta.  While 
this  is  true,  it  must  be  remembered  that  there  may  be  very  marked 
loss  of  blood  and  great  danger  in  cases  of  partial  implantation. 
The  marginal  is  the  most  dangerous  variety  of  partial  implanta- 
tion ;  complete  placenta  previa  is  the  most  serious  of  all  forms. 
Demetin  mentions  39  complete  insertions,  with  a  mortality  of  35.8 
per  cent. ;  Depaul,  25,  with  56  per  cent. 

Weakness  of  uterine  contractions  are  frequent  during  the  first 
stage,  probably  due  to  the  absence  of  pressure  of  the  fetus  against 
the  cervix,  and  this  inertia  favors  the  escape  of  blood. 

The  cervix  usually  is  soft  and  dilates  easily  in  cases  of  placenta 
praevia.  When  the  cervix  tears  badly,  the  hemorrhage  ma}'  be 
very  great ;  when  it  is  firm,  there  is  increased  risk  to  the  mother, 
because  of  the  prolongation  of  the  first  stage  from  slow  or  difficult 
dilatation.  Hence  the  condition  of  the  cervix  makes  placenta 
praevia  more  serious  in  primiparct  than  in  multiparae,  other  things 
being  equal.  Injudicious  interference  may  cause  rupture  of  the 
lower  uterine  segment.  Malpresentations  and  malpositions  of  the 
fetus,  prolapse  and  velamentous  insertion  of  the  cord,  and  placenta 
succenturiata  are  found  more  frequently  in  placenta  praevia  cases 
than  in  those  with  normalh"  implanted  placentae,  and  these  add  to  the 
risks  if  labor  goes  on  unaided  or  if  artificial  delivery  is  carried  out. 
In  133  cases  occurring  in  two  hospitals  in  Breslau,  between  1884 
and  1894,  Boss  found  that  the  presentations  were  as  follows  :  Head, 
66.2  per  cent. ;  breech,  1.8  per  cent. ;  footling,  8  per  cent. ;  trans- 
verse, 24  per  cent.  The  risks  are  greater  to  those  who  are  en- 
feebled by  repeated  hemorrhage  previous  to  labor  than  to  those 
who  first  lose  blood  during  labor.  The  reaction  of  the  woman  to 
the  loss  of  blood  is  an  important  factor.  Great  variations  are 
found.  One  patient  may  suffer  little  as  the  result  of  a  hemorrhage 
that  might  be  very  serious  to  another. 

The  fetus  is  in  danger  of  asphyxiation  from  separation  of  the 
placenta  and  interference  with  the  circulation  of  maternal  blood  in 
the  intervillous  space.  It  may  also  be  endangered  b}'  premature 
or  artificial   delivery  and   by  interference  with   the   cord.     In  the 


PLACENTA    PR ^E VIA.  551 

third  stage  trouble  may  be  caused  by  adherent  placenta,  which, 
according  to  Miiller,  is  found  in  39  per  cent,  of  cases.  Sometimes 
a  complete  placenta  praevia  is  delivered  before  the  fetus.  J.  Y. 
Simpson  collected  statistics  of  141  such  cases,  with  a  maternal 
mortality  of  10  per  cent.  After  labor  there  is  increased  risk  of 
inertia  uteri,  hemorrhage,  and  septic  infection  ;  phlebitis  is  ex- 
ceptionally frequent.  Death  is  sometimes  due  to  embolism  from 
air  entering  open  veins  in  the  placental  site.  The  patient  may  be 
very  weak  in  the  puerperium  and  may  recover  slowly.  Involution 
of  the  uterus  is  retarded. 

Before  the  seventh  month  of  gestation  the  maternal  risks  in 
connection  with  hemorrhage  and  the  expulsion  of  the  ovum  are 
very  much  less  than  in  the  last  two  or  three  months  of  pregnancy. 
Death  has  rarely  been  due  to  hemorrhage  in  the  first  six  months. 

Various  statistics  of  mortality  are  found.  Since  the  beginning 
of  antiseptic  technic  there  has  been  a  reduction  in  the  death  rate, 
this  being  due  both  to  cleanliness  and  to  improved  treatment. 
The  following  statistics  of  maternal  mortality  are  given  by  old 
authorities — /.  e.,  J.  Y.  Smipson,  33.3  per  cent. ;  Hugenberger,  38 
per  cent. ;  Depaul,  32  per  cent. ;  Spiegelberg,  30  per  cent. 

In  recent  times  Labusquiere  mentions  2.36  per  cent,  in  169 
cases.  It  is  interesting  to  note  his  analysis  of  these.  In  109  labor 
occurred  spontaneously  and  without  fatality  ;  in  60  cases,  where 
interference  was  considered  necessary,  the  death  rate  was  6.66  per 
cent.  Of  these  60  cases  the  membranes  were  simply  ruptured  in 
36,  labor  taking  place  without  fatality ;  in  the  remaining  24  other 
forms  of  interference  were  carried  out  and  4  deaths  occurred — /.  e., 
the  entire  mortality  belonged  to  those  cases  in  which  artificial 
manipulations  other  than  rupturing  the  membranes  were  carried 
out.  Tarnier  and  Budin  give  a  rate  of  21.05  P^^  cent,  in  62  cases, 
and  Barnes,  8.8  per  cent,  in  67  cases.  Winckel  thinks  that  the 
maternal  mortality  should  be  between  5  and  10  per  cent. 

The  fetal  mortality  is  high.  J.  Y.  Simpson  estimated  it  at  67 
per  cent. ;  Depaul,  at  62  per  cent.  When  the  placenta  is  born 
first  the  fetus  almost  always  dies.  In  premature  delivery  the 
death  rate  is  very  high  ;  and  even  if  the  fetus  is  alive  at  birth  it  is 
likely  to  die  soon. 

Treatment. — i.  Before  the  Fetus  is  Viable. — The  treatment 
of  hemorrhage  in  the  early  months  of  pregnancy  has  already 
been  considered  in  connection  with  abortion.  When  bleeding 
from  placenta  praevia  occurs  shortly  before  viability,  many  authori- 
ties hold  that  the  question  of  palliative  treatment  must  always  be 
considered  in  the  interests  of  the  fetus,  since  maternal  death  is  a 
very  rare  event  before  the  end  of  the  seventh  month.  If  the 
hemorrhage  be  excessive  at  first  or  continuous,  or  if  the  fetus 
dies,  it  is  generally  held  that  the  pregnancy  should  be  terminated. 
When   there  is  a  slight  loss  of  blood,  which  ceases,  an  effort  may 


552  •,  COMPLEX  LABOR. 

be  made  to  carry  the  patient  along  until  the  fetus  is  viable,  pro- 
vided that  the  conditions  are  such  as  ensure  prompt  attendance 
when  medical  attention  is  needed.  Such  a  course  can  best  be 
adopted  by  placing  the  patient  in  a  well-equipped  hospital.  The 
woman  should  be  put  to  bed  during  the  waiting-period,  the 
bodily  functions  being  carefully  regulated.  In  such  cases  the 
pulse  and  general  condition  must  be  carefully  watched  if  there  be 
a  succession  of  slight  hemorrhages,  for  these  as  well  as  a  sudden 
excessive  flow  may  in  time  reduce  the  woman.  Interference 
should  not,  therefore,  be  delayed  too  long. 

2.  After  the  Fetus  is  Viable. — If  palliative  treatment  has 
been  carried  out,  labor  should  be  induced  after  viability  is  certain, 
if  the  placenta  praevia  be  central  or  marginal.  If  it  be  lateral, 
the  pregnancy  may  be  allowed  to  continue  if  there  be  no  more 
bleeding.  As  already  stated,  the  risks  increase,  especially  during 
the  last  two  months. 

The  method  of  interfering  in  placenta  praevia  to  the  best  ad- 
vantage of  the  mother,  without  reference  to  the  preservation  of 
the  fetus,  is  one  that  is  ver}'  generally  in  favor.  Different  pro- 
cedures are  recommended,  each  of  which  has  its  advocates. 
Thev  should  have  in  view  the  checking  of  hemorrhage,  the 
dilatation  of  the  cervix,  and  the  delivery  of  the  fetus.  It  is 
important  that  the  procedure  adopted  should  not  have  as  its  end 
one  of  the  results  at  the  expense  of  the  others,  though,  of  course, 
one  must  be  cho.sen  whose  prime  object  is  the  checking  of  the 
hemorrhage. 

In  any  condition  of  placenta  praevia  bleeding  may  be  very 
often  completely  checked  by  a  firm  tamponade  of  the  vagina,  a 
long  continuous  strip  (or  several  strips  tied  together)  of  wet 
aseptic  or  antiseptic  gauze — c.  g.,  chinosol — being  most  convenient 
for  the  purpose.  It  is  best  introduced  when  the  woman  is  in  the 
genupectoral  or  elevated  lithotomy  posture,  the  vulva  being  opened 
with  a  spatular  speculum.  The  external  genitals  should  have  been 
previously  shaved  and  cleansed,  and  the  bowels  and  bladder  should 
be  emptied.  The  vagina  need  not  be  washed  out  beforehand  if 
manipulations  have  not  been  employed  that  may  have  introduced 
infecting  organisms.  In  an  emergency  in  a  private  house,  strips 
of  sheeting  3  in.  wide,  boiled  in  water  containing  soda  for  fifteen 
minutes,  may  be  used  instead  of  gauze. 

The  woman  should  then  be  kept  quiet  in  bed  and  should  be 
under  the  observation  of  the  medical  attendant  or  a  skilled 
assistant.  If  there  be  no  bleeding,  the  patient's  pulse  remaining 
satisfactory,  many  authorities  leave  the  plug  in  position  for  six  or 
eight  hours.  Frequently  its  presence  induces  labor  pains,  which 
lead  to  dilatation  of  the  cervix.  At  the  end  of  the  time  stated 
the  tampon  may  be  removed.  If  the  cervix  is  dilating  satisfac- 
torily and  little  blood  has  been  lost  many  recommend  reinsertion 


PLACENTA    PRMVIA.  553 

of  the  tampon,  labor  being  allowed  to  proceed  naturally.  Be- 
tween pains  the  fetus  may  be  pressed  downward  through  the 
fundus,  in  order  to  push  the  placenta  against  the  lower  segment 
and  cervix  ;  the  uterus  is  also  stimulated  by  this  manipulation. 
When  the  cervix  is  well  dilated  the  tampon  may  be  removed  and 
the  bag  of  membranes  ruptured ;  the  consequent  descent  of  the 
presenting  part  may  completely  or  nearly  check  hemorrhage. 
Downward  pressure  of  the  fetus  through  the  fundus  between 
pains  is  a  valuable  adjunct.  At  the  time  of  rupturing  the  mem- 
branes, correction  of  a  faulty  position  or  presentation  may  be 
made,  and  turning  may  be  carried  out  if  deemed  advisable.  If 
there  be  a  cephalic  presentation  that  is  allowed  to  proceed  nor- 
mally, forceps  may  be  used  if  there  be  delay  after  the  head  has 
entered  the  true  pelvis. 

This  method  of  procedure  is  very  frequently  satisfactory  to 
the  mother  (Winckel  giving  a  maternal  mortality  of  5.2  per  cent.) 
and  offers  good  chances  to  the  fetus.  In  the  hands  of  those  who 
are  not  accustomed  to  obstetric  manipulations  and  who  have  not 
the  facilities  of  a  hospital  at  hand,  it  is  perhaps  the  safest  method 
to  be  employed.  An  objection  to  it  is  the  delay  and  worry  to 
which  the  patient  may  be  subjected,  especially  when  the  first 
tamponade  does  not  excite  labor  pains.  The  patient  may  get  no 
sleep  and  may  become  worn  and  restless.  The  bowel  and  urethra 
may  be  so  compressed  that  natural  evacuations  are  impossible,, 
and  regular  catheterization  of  the  bladder  may  be  required. 

Many  authorities  employ  the  tampon  for  six  or  eight  hours  in 
order  to  obtain  some  degree  of  dilatation,  but  it  is  not  always 
certain  to  bring  this  about.  Others  use  it  only  to  check  hemor- 
rhage until  preparations  can  be  made  for  other  methods  of  pro- 
cedure. When  the  patient  can  be  attended  at  once,  these  may  be 
carried  out  without  previous  tamponade.  Instead  of  vaginal 
tamponade,  plugging  of  the  cervix  may  be  employed.  For  this 
purpose  a  Barnes's  bag  distended  with  normal  saline  solution  may 
be  introduced  without  rupturing  the  membranes.  It  checks 
bleeding,  dilates  the  cervix,  and  stimulates  the  uterine  pains. 
The  patient  requires  to  be  closely  watched,  however,  as  it  may 
rupture  or  be  forced  into  the  vagina  as  the  cervical  canal  enlarges,, 
and  fresh  bleeding  may  occur. 

Of  greater  service  is  the  Champetier  de  Ribes  bag  intro- 
duced into  the  cervix,  below  or  within  the  amniotic  cavity 
(in  a  complete  placenta  praevia  it  should  be  placed  within).  It 
rarely  bursts,  presses  against  the  lower  uterine  segment,  dilates 
the  cervix,  and  only  passes  through  the  cervix  when  the  latter  is 
dilated  sufficiently  to  receive  the  head.  After  it  is  expelled  con- 
stant downward  pressure  must  be  exerted  on  the  fetus  through 
the  fundus  in  order  to  check  hemorrhage,  and  the  membranes 
should  be  ruptured  if  this  has  not  already  taken  place.     If  bleed- 


554  .  COMPLEX  LABOR. 

ing  be  not  controlled  in  this  way  until  the  head  has  well  entered 
the  cervix,  it  is  advisable  to  deliver  by  turning  or  by  forceps  ; 
preferably  by  the  latter  method  if  the  cervix  be  fully  dilated,  as 
the  fetus  probably  has  a  better  chance.  The  chief  objection  to 
the  use  of  this  bag  is  that  it  frequently  displaces  the  fetus  and 
may  thus  complicate  the  labor ;  thus,  it  may  change  a  vertex  to  a 
transverse  presentation.  Such  a  change  may  usually  be  detected 
by  careful  abdominal  palpation  through  the  abdomen.  The  dis- 
placement must  be  corrected  as  soon  as  the  bag  is  delivered 
through  the  cervix. 

Among  those  who  employ  the  above  methods  only  for  the 
temporary  control  of  bleeding  the  following  procedure  is  a  favorite 
one,  much  practised  at  the  present  time :  If  the  cervix  will  not 
admit  two  fingers  its  canal  should  be  enlarged  with  metal  dilators, 
fingers,  or  Barnes's  bag  until  the  fingers  can  be  easily  introduced. 
In  the  great  majorit\-  of  cases,  owing  to  the  abnormal  softness  of 
the  cervix,  the  dilatation  may  be  accomplished  mainly  by  the 
fingers  (perhaps  being  begun  with  the  dilators),  the  bags  being 
rarely  needed.  The  bipolar  or  Braxton  Hicks  method  of  version 
is  then  performed,  the  membranes  being  preserved.  When  the 
placenta  is  marginal  the  fingers  should  be  placed  against  the 
membranes  near  its  edge. 

If  the  placenta  entirely  cover  the  cervix  the  fingers  must  be 
pushed  through  the  thickness  of  the  villi  but  not  through  the 
amnion.  Preser\ation  of  the  amnion  is  essential  to  speedy  and 
satisfactory  turning  of  the  fetus  by  this  method.  (See  Version.) 
When  the  fetus  lies  transversely,  turning  is  more  quickly  accom- 
plished than  when  the  head  presents.  When  the  breech  presents, 
of  course  version  is  not  necessaiy.  When  the  breech  is  brought 
near  the  cei"vix,  two  fingers  are  pushed  into  the  amniotic  cavity  in 
order  to  seize  one  or  both  feet,  which  are  then  drawn  through  the 
cervix ;  both  being  preferable  if  they  are  accessible  and  can  be 
drawn  down.  The  fetus  now  acts  as  an  efficient  compress  against 
the  lower  uterine  segment  as  well  as  a  dilator  of  the  cervix,  and 
delivery  may  take  place  naturally  without  any  more  bleeding. 
Should  any  be  noted,  it  may  be  checked  b}'  pressure  of  the  fetus 
downward  through  the  fundus,  between  pains,  or  by  keeping  up 
slight  traction  on  the  limb  of  the  fetus.  The  case  should  never 
be  left  without  a  medical  attendant. 

Rarely  it  is  advisable  to  interfere  if  the  labor  does  not  take 
place  satisfactorily  b\'  the  natural  powers,  or  if  the  patient  is  ex- 
hausted. Dilatation  of  the  cervix  may  be  hastened  by  careful 
traction  on  the  fetus,  assisted  by  digital  manipulations,  steady 
pressure  being  exerted  on  the  fundus  as  the  fetus  descends.  When 
the  body  has  passed  through  the  cervix  the  latter  tends  to  retract 
on  the  neck.  If  dilatation  be  not  sufficient  for  the  passage  of  the 
head,  rupture  of  the  cervix  and  lower  segment  may  result,  greatly 


PLACENTA    PRyEVIA.  555 

increasing  the  risk  to  the  woman.  If  the  fetus  be  dead,  the 
simplest  plan  is  the  reduction  of  the  size  of  the  head  by  perfora- 
tion through  the  base  of  the  occiput  (or  sometimes  the  roof  of  the 
mouth).  As  the  brain  matter  escapes  the  head  may  be  extracted 
without  more  dilatation. 

When,  however,  there  is  a  chance  of  a  living  child  the  cervix 
must  be  dilated  carefully  with  the  fingers  and  the  head  delivered. 
After  the  birth  of  the  child  it  is  best  to  separate  and  remove  the 
placenta  by  the  introduction  of  the  hand  into  the  uterus.  This  is 
especially  advisable  on  account  of  the  frequency  of  adherent  pla- 
centa. Thereafter  the  uterine  body  should  be  compressed  and 
steadied  by  an  assistant  while  a  long  gauze  tampon  is  firmly  packed 
from  the  fundus  to  the  vulva.  An  assistant  or  nurse  should  sit 
by  the  patient  for  at  least  an  hour  after  delivery,  keeping  a  hand 
on  the  uterine  body  through  the  abdominal  wall,  and  kneading  it 
if  relaxation  occurs. 

Immediately  after  labor,  also,  two  pints  of  warm  normal  saline 
enema  may  be  given  by  a  high  rectal  tube.  This  may  indeed  be 
administered  at  any  time  in  labor,  except  in  the  second  stage,  if 
considerable  blood  has  been  lost.  If  immediate  addition  of  the 
solution  is  urgently  needed  at  any  time,  it  may  be  injected  under 
the  breasts.  Transfusion  into  the  blood  is  rarely  necessary.  The 
lower  end  of  the  bed  should  be  elevated.  In  the  early  puerperium 
the  patient  must  be  kept  exceptionally  quiet.  If  much  blood  has 
been  lost  the  foot  of  her  bed  may  be  elevated  for  a  day  or  two. 
Ergot  should  be  administered  for  a  few  days. 

The  chief  disadvantage  in  the  method  of  treatment  just  de- 
scribed is  the  large  fetal  mortality.  Undue  haste  in  delivery  may 
cause  bad  rupture  of  the  cervix  and  lower  uterine  segment,  and 
this  may  lead  to  increased  hemorrhage. 

During  ten  years,  1889-99,  74  cases  were  treated  in  the  Dublin 
Rotunda  by  turning,  drawing  a  foot  through  the  cervix,  and 
leaving  the  rest  to  nature,  except  when  bad  hemorrhage  con- 
tinued. Of  these  cases  only  28  occurred  at  full  time.  Nine  only 
were  complete.  Four  maternal  deaths  took  place :  i  from  pul- 
monary embolism  on  the  eighteenth  day,  2  from  septic  infection 
introduced  before  the  patients  were  admitted  to  hospital,  and  i 
from  hemorrhage  following  the  application  of  forceps,  which  rupt- 
ured the  uterus. 

Some  mention  may  be  made  of  other  methods  of  treatment. 

Rupture  of  the  membranes  is  advised  by  some  as  soon  as  the 
condition  is  diagnosed,  especially  in  high  lateral  placenta  prasvia. 
This  certainly  is  calculated  to  check  the  hemorrhage,  but  it  leads 
to  a  very  tedious  labor  and  makes  version  difficult  or  impossible, 
and  increases  the  risks  to  the  mother  and  fetus  ;  it  is  admissible 
only  when  the  head  or  breech  presents.  In  cases  where  the  mem- 
branes have  ruptured  early  it  is  advisable  to  introduce   a  Cham- 


556  ^  COMPLEX  LABOR. 

petier  de  Ribes  bag  in  order  to  promote  dilatation.  Thereafter 
delivery  may  occur  naturally,  though  forceps  or  embryulcia  may 
be  necessary  ;  turning  can  rarely  be  safely  carried  out  on  account 
of  uterine  retraction. 

Separation  of  the  lower  part  of  the  placenta  was  advocated 
by  Barnes  in  cases  of  partial  implantation.  It  frequently  checks 
hemorrhage  and  allows  dilatation  to  take  place  more  rapidly.  It 
is  not  certain  in  its  results,  however,  and  the  effect  on  the  fetus  is 
very  bad. 

Separation  of  the  whole  placenta  was  proposed  by  J.  Y.  Simp- 
son on  the  ground  that  it  does  no  harm,  may  diminish  bleeding, 
and  promote  dilatation.  It  should  not  be  employed  if  the  fetus  be 
alive  or  viable. 

Rapid  manual  dilatation  of  the  cervix  may  occasionally  be 
safely  carried  out,  but  it  is  veiy  risky.  The  chance  of  tearing 
the  cervix  and  lower  uterine  segment  and  of  increasing  the 
hemorrhage  is  great.  Moreover,  if  the  woman  has  lost  much 
blood,  this  procedure,  followed  by  rapid  deliver}-,  maybe  too  much 
of  a  shock  to  her  system  and  may  prove  fatal.  It  is  really  ad- 
missible only  when  the  cervix  is  nearly  fully  dilated  and  it  is 
desirable  to  complete  the  labor  by  version  or  forceps. 

Csesarean  Section. — Within  the  last  few  years  abdominal  Cae- 
sarean  section  has  been  carried  out  in  several  cases  of  placenta 
prsevia.  It  was  first  recommended  by  Lawson  Tait.  The  pro- 
cedure has  been  severely  criticized  by  several  authorities.  Zinke 
has  collected  6  cases  of  the  conservative  operation  and  2  of 
Porro's  operation,  in  which  5  mothers  and  6  infants  lived.  This 
author  holds  that  in  central  placenta  prsevia,  when  the  patient  is  a 
primipara,  the  os  closed,  hemorrhage  profuse,  and  separation  of 
the  placenta  around  the  internal  os  difficult,  the  Caesarean  orPorro 
operation  is  legitimate  and  elective.  Webster  has  reported  the 
case  of  a  young  girl  in  which  excessive  hemorrhage,  associated 
with  a  small  vagina  and  pelvis  and  a  transverse  presentation  of  the 
fetus,  necessitated  Cresarean  section.     (See  Cresarean  Section.) 

HEMORRHAGE  FROM  PREMATURE  DETACHMENT  OF  THE  NORMALLY 
SITUATED  PLACENTA  (ABLATIO  PLACENTAE  ;  ACCIDENTAL  HEM- 
ORRHAGE). 

Bleeding  in  early  pregnancy,  associated  with  separation  of  the 
normally  placed  placenta,  has  already  been  studied  in  connection 
with  the  subject  of  abortion.  It  now  remains  to  consider  the  cases 
in  which  such  hemorrhage  occurs  in  advanced  gestation.  To  it 
the  name  of "  accidental  "  was  given  by  Rigby,  as  opposed  to 
"  unavoidable,"  the  term  used  in  describing  the  hemorrhage  of 
placenta  praevia.  Rudolph  W.  Holmes  has  recently  proposed  the 
term  "  ablatio  placentse." 

Frequency. — Accurate  statistics  cannot  be  given,  as  there  is 


HEMORRHA  GE.  557 

little  doubt  that  in  literature  many  cases  of  accidental  hemorrhage 
have  been  tabulated  as  placenta  praevia.  Moreover,  slight  pla- 
cental detachments,  accompanied  by  clotting  in  the  area  of  sepa- 
ration and  leading  to  no  disturbance,  are  not  infrequent,  and  these 
are  not  included  in  the  statistics  by  most  writers.  Spiegelberg 
called  special  attention  to  these.  Broadhead  noted  57  instances 
in  5900  cases  in  the  Sloane  Maternity,  visible  antepartum  hemor- 
rhage having  been  present.  In  1000  cases,  7  had  putty-like  gray 
clots. 

Of  the  frequency  of  ablatio  as  a  cause  of  serious  disturbance 
from  loss  of  blood  externally  or  concealed,  it  is  impossible  to 
speak  with  accuracy.  In  3000  labors  occurring  in  the  Chicago 
Lying-in  Hospital  and  Dispensary,  6  cases  were  noted,  in  only  2 
of  which  treatment  was  necessary.  Tissier  found  that  in  six 
years'  service  at  two  large  clinics  in  Paris  the  percentage  was 
about  I  in  1000.  The  New  York  Lying-in  Hospital  reports 
10,000  cases,  with  i  accidental  hemorrhage.  Churchill  reported 
68,982  labors  with  85. 

!^tiolog"y. — There  has  been  much  speculation  as  to  the  causes 
of  the  separation  of  the  placenta.  It  has  long  been  held  that  the 
arrangement  of  the  uterine  circulation — viz.,  the  enormous  ramifi- 
cation of  uterine  sinuses,  drained  mainly  by  the  ovarian  and  uterine 
veins — predisposes  to  blood-stasis,  and  that  whatever  causes  ex- 
cessive engorgement  might  tend  to  produce  retroplacental  hemor- 
rhage, as  Jacquemier  first  suggested. 

Traumatism  has  long  been  considered  an  important  factor,  but 
it  is  probably  less  frequently  a  direct  cause  than  is  generally  be- 
lieved. There  is  no  doubt  that  violent  injury  may  cause  imme- 
diate separation  and  hemorrhage,  but  in  many  cases  in  which  the 
bleeding  is  attributed  to  some  form  of  exertion  or  unimportant 
accident,  the  real  cause  is  a  diseased  condition  of  the  decidua  or 
chorionic  viUi.  Inflammation  in  the  decidua  serotina  is  indeed 
generally  considered  to  be  a  frequent  cause.  Separation  is  more 
frequent  in  multiparas  than  in  primiparae.  Holmes  has  pointed 
out  that  in  1 56  cases,  19.2  per  cent,  were  primiparae.  He  also  noted 
that  in  17  per  cent,  of  cases  ablatio  occurred  in  women  between 
the  ages  of  sixteen  and  twenty-five  ;  in  53.7  per  cent,  in  those  be- 
tween twenty-six  and  thirty-five  ;  in  29.8  per  cent,  in  those  between 
thirty-six  and  forty-five.  As  to  the  period  of  gestation,  ablatio 
was  reported  6  times  in  the  fifth  month,  4  times  in  the  sixth,  29  in 
the  seventh,  62  in  the  eighth,  and  52  in  the  ninth. 

In  a  considerable  number  of  instances  congestion  of  the  de- 
cidua is  secondary  to  renal  changes,  as  was  first  described  by  Blot, 
in  1849.  It  has  also  been  noted  in  tuberculosis,  heart  disease, 
alcoholism,  syphiUs,  and  exophthalmos.  Arterial  degeneration 
may  also  be  a  cause.  The  acute  infectious  diseases  sometimes 
lead  to  placental  separation.     Diseased  conditions  of  the  placenta 


558 


COMPLEX  LABOR. 


Upper  end_ 


are  usually  mentioned,  though  little  is  known  regarding  them.  It 
is  evident  that  separation  of  a  portion  of  the  placenta  might  readily 
take  place  if  the  villi  attached  to  the  serotina  be  so  degenerated  as 
to  be  easily  torn.  It  must  here  again  be  pointed  out  that  the  im- 
portance of  the  placenta  as  a  causal  factor  has  probably  been 
exaggerated,  from  the  frequency  with  which  infarcts,  so-called, 
have  been  noted  in  the  placenta.  In  the  past  these  have  always 
been  considered  as  resulting  from  hemorrhages,  whereas  recently 
they  have  clearly  been  demonstrated  as  localized  formations  of 
iibrin,  caused  by  degenerative  changes  in  the  villi.  (See  p.  66.) 
AbnormaHties  in  the  ovum  have  been  noted  in  association  with 

ablatio  in  some  cases — c.  g., 
malpositions  and  malpresenta- 
tions,  and  shortness  of  the 
cord. 

Pathologic  Anatomy. 
— In  cases  where  a  small 
hemorrhage  occurs  between 
the  placenta  and  uterus,  in- 
sufficient to  produce  any  sign 
or  s}-mptom  where  it  may  be 
recognized,  the  clot  usually 
organizes  and  forms  a  firm 
mass  of  fibrin.  Sometimes  it 
may  give  rise  to  a  cystic  forma- 
tion. In  cases  in  which  dis- 
tinct signs  and  symptoms  are 
present,  two  varieties  are  usu- 
ally described — viz.,  apparent 
and  concealed  hemorrhage. 

By  the  first  is   meant  the 
passage    of   blood    from    the 
separated  area  downward  be- 
tween   the    membranes     and 
uterus  and  through  the   cer- 
vical   canal ;    by  the   second, 
the     accumulation     of    blood 
between  the  placenta  or  pla- 
uterine  wall,  or  in  the   amniotic 
having    occurred,  no   escape 
In   some   cases   of  apparent 
that    is    poured    out    escapes 
cases    only   a  small    amount 


Fig.  249. — Accidental  hemorrhage.  Blood 
collected  between  placenta  and  part  of  mem- 
branes and  the  uterine  wall  ( Pinard  and 
Varnier). 

centa  and  membranes   and  the 


cavity,  rupture   of  the   membranes 

through   the   cervix  taking   place. 

hemorrhage,    most    of    the    blood 

through   the    cervix,  but  in   other 

may   appear    externalh%    the    greater   part    accumulating    inside 

the  uterus.      Thus,  the  quantity  of  blood   passing  through  the 

cervix  may  be   no  index  whatever  of  the   actual    extent  of  the 

hemorrhage.     Occasionally  clotting  takes  place  along  the  track 


HEMORRHAGE. 


559 


of  the  escaping  blood,  so  that  a  mass  of  fibrin  is  formed  that  may 
extend  into  the  cervix ;  in  these  cases  only  the  clear  blood-serum 
may  pass  downward  through  the  cervix.  This  process  may 
gradually  be  followed  by  complete  checking  of  the  hemorrhage. 
Clotting  also  tends  to  occur  at  the  primary  seat  of  hemorrhage 
unless  death  or  delivery  takes  place  at  an  early  stage.  The  clots 
are  found  in  various  stages,  according  to  the  period  of  their  for- 
mation. In  the  concealed  form,  according  to  Goodell,  the  placenta 
may  be  detached  everywhere  except  around  the  margin  ;  it  may 
also    be    detached    at    the 


JVar 


€ 


m/m/ih) 


margin,  the  adjacent  mem- 
branes being  adherent  or 
separated  for  a  distance, 
the  blood  collecting  under 
them.  In  the  latter  condi- 
tion the  blood  may  be  pre- 
vented from  passing  through 
the  cervix  by  a  clot  near 
the  OS  internum  or  by  the 
pressure  of  the  presenting 
part  of  the  fetus.  Holmes 
suggests  that  firm  closure 
of  the  OS  internum  may 
sometimes  also  prevent  its 
escape.  Very  rarely  the 
blood  may  burst  into  the 
amniotic  cavity  and  mix 
with  the  amniotic  fluid. 

As  the  placenta  is  sepa- 
rated it  is  bulged  toward 
the  amniotic  cavity.  It 
may  be  pushed  against  and 
moulded  by  the  fetus.  The 
blood-mass  may  be  some- 
what regular  or  irregular, 
the  placenta  being  separated 
with  no  uniformity.  Very  rarely  detachment  is  accompanied  with 
prolapse  of  the  placenta ;  sometimes  the  separation  may  be  com- 
plete and  yet  no  blood  escape  from  the  uterus. 

Symptoms  and  Signs. — Great  variations  are  found.  No 
symptoms  whatever  are  produced  when  slight  detachment  and 
localized  clotting  occurs,  the  condition  being  discovered  only 
after  delivery  of  the  placenta.  In  well-marked  cases  the  symp- 
toms and  signs  associated  with  loss  of  blood  are  present.  These 
vary  according  to  the  suddenness  and  extent  of  the  hemorrhage 
and  to  the  strength  and  resistance  of  the  patient.  In  the  most 
serious    acute   cases,   especially  of  the   concealed   type,   there  is 


Fig.  250. — Premature  detachment  of  the 
placenta  occupying  its  normal  site.  Frozen 
section  of  an  undelivered  woman  dead  of 
eclampsia  (after  Dr.  Winter).  A  blood-mass 
under  the  placenta. 


560  COMPLEX  LABOR. 

sudden  collapse,  weakness,  pallor,  and  sometimes  syncope.  The 
woman  becomes  restless  and  cold,  presenting  sighing  respirations, 
her  pulse  being  rapid  and  feeble.  Frequently  there  is  distress  in 
the  region  of  the  uterus,  variously  described  as  pain,  cramps, 
pressure,  and  stretching ;  the  pain  may  sometimes  be  localized. 
Blood  may  soon  escape  through  the  cervix  in  these  severe  cases, 
though  it  is  usually  small  in  quantity  and  is  often  absent.  It  is 
of  the  greatest  importance  that  the  physician  does  not  estimate 
the  gravity  of  a  case  by  the  amount  of  visible  blood.  In  these 
acute  severe  hemorrhages  death  may  rapidly  take  place  unless 
treatment  be  carried  out.  In  another  type  of  case  the  symptoms 
of  anemia  may  develop  slowly  during  the  course  of  several 
hours,  a  considerable  quantit}'  of  blood  escaping  through  the 
cervix,  little  or  no  abdominal  distress  being  felt.  Rarely  after  the 
primary  hemorrhage  there  may  be  an  oozing  of  blood  or  serum, 
more  or  less  continuous,  for  several  days.  In  such  cases  the 
patient  may  become  ver}-  anemic. 

Labor  may  frequenth-  be  induced  by  accidental  hemorrhage. 
During  uterine  contractions,  though  the  uterine  vessels  may  be 
completely  closed,  there  is  not  necessarily  any  diminution  in  the 
amount  of  blood  that  may  be  escaping  through  the  cervix.  On 
the  contrary,  it  may  be  increased  by  the  action  of  the  uterus  in 
forcing  downward  blood  that  has  accumulated  in  the  uterus.  On 
physical  examination  various  conditions  are  found.  In  cases 
where  the  hemorrhage  is  not  marked  palpation  of  the  uterus 
reveals  nothing  unusual.  When  much  blood  accumulates  the 
uterus  may  be  considerably  enlarged,  feeling  boggy  when  con- 
tractions are  not  present ;  or  it  may  be  continuously  more  tense 
than  normally.  The  enlargement  may  or  may  not  be  .sym- 
metrical. The  woman  may  or  may  not  complain  of  soreness 
over  the  whole  organ.  When  the  placenta  is  situated  on  the 
anterior  wall  or  fundus  the  accumulated  blood  may  cause  a  dis- 
tinct bulging  of  the  wall,  which  may  be  palpated,  usually  with 
the  production  of  pain.  The  fetal  parts  may  be  very  indistinctly 
felt ;  the  fetal  heart  sounds  may  not  be  heard,  or  if  heard  are 
often  slow,  weak,  and  irregular.  When  the  placenta  is  posterior 
the  fetus  may  sometimes  be  pushed  firmly  against  the  anterior 
wall,  so  that  its  irregularities  may  be  visible. 

Frequently  on  vaginal  examination  nothing  abnormal  can  be 
detected.  Clots,  fresh  blood,  or  serum  may  be  found  in  the 
passages  when  external  hemorrhage  takes  place.  Sometimes  a 
blood-mass  in  the  lower  segment  may  cause  the  fornix  vaginae  to 
feel  boggy.  When  the  cervix  is  dilated  recent  blood-clot  may  or 
may  not  be  felt.  Occasionally,  when  a  fibrinous  clot  has  formed, 
it  may  be  felt  as  a  stringy,  friable  mass,  which  may  be  mistaken 
for  the  placenta.  The  placenta  itself  cannot  be  felt  save  in  the 
rare  cases  where  it  is  prolapsed.     When  the  membranes   rupture 


HEMORRHA  GE.  5  6 1 

the  liquor  amnii  may  be  darkened  by  the  admixture  of  blood ; 
this  is,  however,  a  rare  occurrence.  Some  authors  believe  that 
occasionally  there  may  be  a  transudation  of  blood  through  un- 
ruptured membranes.  In  many  cases  the  escaping  amniotic  fluid 
is  tinged  by  the  blood  lying  in  the  cervix  and  vagina.  In  labor, 
as  the  fetus  or  placenta  is  dehvered,  clots  or  fluid  blood  that  has 
been  concealed  escapes. 

Differential  Diagnosis. — Difficulty  may  arise  in  estabUsh- 
ing  a  diagnosis.  Some  of  the  general  symptoms  may  resemble 
those  found  in  certain  forms  of  acute  poisoning,  in  the  rupture  of 
an  aneurism,  or  in  pulmonary  embohsm,  but  in  these  the  uterine 
changes  are  absent.  Similar  local  and  general  signs  and  symp- 
toms may  be  found  in  rupture  associated  with  ectopic  gestation. 

Rupture  of  the  uterus  may  simulate  ablatio,  but  rarely  is 
found  apart  from  advanced  labor.  If  the  fetus  has  escaped 
through  the  uterus  the  latter  is  correspondingly  reduced  in  size, 
unless  relaxed,  and  labor  pains  cease.  Acute  hydramnios  must 
also  be  noted ;  in  this  condition  the  anemia  is  wanting.  Fainting 
in  a  pregnant  woman  from  causes  other  than  loss  of  blood  may 
be  mistaken  for  that  due  to  hemorrhage. 

Those  cases  in  which  external  bleeding  is  present  must  be 
diagnosed  from  cases  of  pregnancy  in  which  external  hemorrhage 
is  due  to  other  causes — e.  g.,  endometritis,  cervical  polypi,  and 
carcinoma.  In  the  latter  conditions  physical  examination  usually 
establishes  a  diagnosis ;  in  endometritis  there  is  never  a  sudden 
development  of  anemia,  but  there  may  be  a  resemblance  to  those 
cases  of  ablatio  in  which  there  is  no  marked  disturbance,  the  blood 
being  lost  gradually  in  small  amounts  only. 

The  greatest  difficulty  may  sometimes  be  experienced  in  diag- 
nosing ablatio  placentae  from  placenta  praevia.  In  the  latter  con- 
dition there  is  never  any  local  pain  or  distress,  such  as  is  present 
in  many  cases  of  the  former.  The  blood  that  escapes  is  generally 
bright  red,  whereas  in  ablatio  it  is  frequently  dark-colored.  If  the 
cervix  be  dilated  digital  exploration  can  detect  no  placenta  in 
ablatio  save  in  the  very  rare  conditions  in  which  it  is  detached  and 
prolapsed.  In  some  cases  of  lateral  placenta  praevia  it  may  be 
impossible  to  feel  the  edge  unless  the  cervix  be  greatly  dilated. 
If  the  cervix  be  placed  abnormally  high  or  the  vagina  be  not 
roomy  the  difficulty  of  establishing  a  diagnosis  is  increased.  The 
uterus  does  not  become  distended  in  placenta  praevia.  Sometimes 
a  mass  of  fibrin  that  has  formed  inside  the  cervix  may  feel  very 
much  like  placental  tissue ;  its  exact  nature  can  only  be  deter- 
mined by  microscopic  examination.  Sometimes  the  nature  of 
a  case  may  be  determined  only  after  the  placenta  is  delivered. 
In  ablatio  the  opening  in  the  membranes  through  which  the 
fetus  is  born  is  not  near  the  placenta,  but  two  or  more  inches 
from  it.     Old  clots  are  frequently  found  in  connection  with  the 


562  ^  COMPLEX  LABOR. 

latter,  which  may  be  moulded  over  them,  near  the  margin  or 
center. 

Prognosis. — The  prognosis  depends  upon  the  amount  of 
hemorrhage,  shock,  the  degree  of  dilatation  of  the  os,  and  its 
dilatability.  Much  depends  on  the  nature  of  the  treatment  em- 
ployed. The  previous  condition  of  the  patient  is  important.  If 
her  health  be  poor  she  is  not  able  to  bear  a  loss  of  blood  that 
might  not  be  dangerous  if  she  were  robust.  The  greater  the 
hemorrhage  the  graver  the  risks.  The  concealed  form  is  much 
more  serious  than  the  external,  since  treatment  is  apt  to  be  delayed. 
The  escape  of  blood  usually  calls  immediate  attention  to  the  con- 
dition, medical  aid  being  summoned,  whereas  in  the  concealed 
variety  the  patient  may  be  moribund  before  she  can  be  helped. 
When  the  patient  does  not  die,  her  after-recovery  is  slow  and  she 
may  be  very  weak  for  a  long  period.  The  danger  of  infection  is 
greater  in  such  cases. 

As  to  statistics,  Braxton  Hicks,  in  i860,  reported  a  maternal 
mortality  of  65.2  per  cent,  in  23  cases  ;  Goodell,  50.9  per  cent,  in 
106  cases;  Tarnier,  7.4  per  cent,  in  27  cases ;  Forin,  35.8  per 
cent,  in  in  cases;  Holmes,  32.2  per  cent,  in  189  cases;  von 
Weiss,  50  per  cent,  in  106  cases. 

As  to  infant  mortality,  Goodell  placed  it  at  94.4  per  cent. ; 
Winter,  at  95  per  cent. ;  Freudenberg,  at  100  per  cent. ;  Forin,  at 
81  per  cent.  ;  Holmes,  at  70  to  85  per  cent.,  according  to  the  treat- 
ment emplo)^ed. 

Treatment. — W' hen  the  hemorrhage  is  slight  palliative  meas- 
ures should  be  adopted.  The  patient  should  be  kept  in  bed  on 
simple  diet  and  an  ice  bag  or  ice  coil  applied  to  the  abdomen. 
The  pulse  should  be  closely  watched  and  the  quantity  of  blood 
lost  externally  carefull}'  estimated.  It  is  useless  to  administer 
ergot  for  the  purpose  of  checking  the  bleeding  from  the  opened 
sinuses,  since  small  doses  are  of  no  avail  and  large  ones  might  in- 
troduce new  dangers.  It  would  be  more  rational  to  endea\or  to 
bring  about  clotting  in  the  effused  blood,  and  for  this  purpose 
calcium  chlorid  should  be  given  in  large  doses— r.^.,  30  gr.  every 
three  hours — by  the  mouth.  By  such  treatment  a  case  may  usually 
be  carried  along  safely,  the  bleeding  gradually  ceasing,  owing  to 
the  formation  of  a  clot,  which  may  afterward  shrink  considerably. 

If  slight  bleeding  continues  in  spite  of  these  measures  the  con- 
dition may  become  serious,  owing  to  the  increasing  anemia.  Preg- 
nancy should  then  be  ended ;  this  may  be  carried  out  by  the 
introduction  of  a  Barnes's  or  Champetier  de  Ribes  bag,  labor 
pains  being  allowed  to  empty  the  uterus,  their  action  being  assisted 
by  the  administration  of  quinin,  if  they  be  not  very  strong.  If  the 
patient  be  weak  or  the  bleeding  increase,  it  is  advisable  to  hasten 
delivery — /.  c,  by  promoting  dilatation  and  performing  version. 
Forceps  may  be  used  only  if  the  cervix  be  fully  dilated. 


HEMORRHA  GE.  5  63 

When  a  considerable  hemorrhage  has  occurred,  but  not  such 
as  to  place  the  woman  in  an  immediately  critical  condition,  she 
should  be  placed  at  absolute  rest  in  bed,  the  lower  end  of  which 
is  elevated.  One  or  two  pints  of  warm  normal  saline  solution 
should  be  injected  into  the  rectum  through  a  long  tube.  In  order 
to  increase  the  coagulability  of  the  blood,  in  the  hope  of  forming 
a  clot  in  the  effused  blood,  a  subcutaneous  injection  of  a  sterilized 
solution  of  gelatin  (10  gr.  or  more)  in  normal  salt  solution  (2  to 
10  per  cent.)  may  be  given  if  the  mixture  can  be  obtained.  The 
cervix  should  then  be  dilated  with  metal  dilators  and  fingers 
or  by  rubber  bags.  If  this  proceeds  easily  without  much  tear- 
ing of  the  cervix,  no  serious  hemorrhage  taking  place,  bipolar 
version  should  be  performed  as  soon  as  the  canal  is  large 
enough  to  permit  of  dehvery.  The  membranes  are  then  rup- 
tured and  the  fetus  slowly  delivered.  During  extraction  firm 
compression  of  the  uterus  through  the  abdominal  wall  must  be 
kept  up  by  an  assistant.  If  the  fetus  be  dead  and  the  passage 
of  the  head  through  the  cervix  be  difficult,  it  is  best  to  perforate 
the  basi-occipital  and  allow  the  brain  matter  to  escape,  so  that  the 
head  is  reduced  in  size.  If  it  is  certain  that  the  fetus  is  dead,  as 
the  cervix  is  being  dilated  it  may  be  more  expeditious  to  perform 
craniotomy  and  extract  rather  than  to  turn  the  child.  In  regard 
to  version,  it  should  always  be  remembered  that  the  manipulations 
necessary  to  carry  it  out  may  sometimes  separate  to  a  greater 
extent  the  already  loosened  placenta,  and  so  may  cause  more 
hemorrhage.  Occasionally  when  the  fetus  is  alive  sufficient 
dilatation  may  be  obtained  to  permit  safe  delivery  with  forceps 
rather  than  by  turning. 

When  in  such  cases  the  cervix  is  so  firm  as  to  make  dilatation 
very  slow  and  difficult,  some  authorities  recommend  that  it  be  in- 
cised, according  to  Diihrssen's  method.  This  procedure  is,  how- 
ever, uncertain  in  its  results  and  not  free  from  grave  risks.  Vagi- 
nal Csesarean  section  is  greatly  to  be  preferred.  The  incisions 
necessary  in  this  operation  need  cause  little  loss  of  blood  if  the 
uterine  arteries  and  divided  branches  of  the  vaginal  arteries  be 
secured  early,  and  if  continual  downward  traction  on  the  cervix  be 
kept  up,  accompanied  with  pressure  on  the  uterus  from  above. 
Abdominal  Caesarean  section  rather  than  the  vaginal  operation  is 
recommended  by  some  authorities.  These  operations,  however, 
should  be  carried  out  only  if  the  circumstances  be  suitable  and 
an  expert  operator  be  at  hand.      (See  Caesarean  Section.) 

There  should  not  be  too  much  delay  in  attempting  dilatation 
in  such  cases,  in  order  that  the  patient's  condition  may  not  be  too 
much  reduced.  Repeated  saline  injections  may  be  necessary  before 
the  delivery  is  finished. 

Finally,  in  cases  of  very  profuse  loss  of  blood  and  shock,  it  is 
difficult  to   decide  which  treatment  is  best.     All   methods  are  apt 


564  "-  COMPLEX  LABOR. 

to  result  in  failure.  Under  most  circumstances  the  best  course  is 
to  rupture  the  membranes  immediately  with  a  finger  or  bougie. 
The  uterus  should  then  be  massaged  through  the  abdominal  wall, 
in  order  to  promote  retraction  on  the  fetus.  A  firm  binder  should 
then  be  fastened  around  the  abdomen ;  bleeding  may  thus  be 
checked.  Efforts  should  then  be  made  to  combat  the  condition 
of  anemia  and  shock  by  sahne  injections  or  transfusion  of  blood, 
elevation  .of  the  lower  end  of  the  bed,  bandaging  of  the  limbs,  etc. 
Later,  labor  pains  may  supervene,  but  dilatation  of  the  cervix 
should  be  promoted  by  artificial  means.  No  thought  need  be 
given  to  the  fetus,  as  it  almost  always  dies  in  such  bad  cases. 
Perforation  of  the  head  may,  therefore,  be  employed  as  soon  as  the 
canal  is  large  enough  to  permit  of  extraction.  In  no  case  should 
ergot  be  administered  while  the  fetus  is  in  the  uterus.  Quinin 
may,  however,  be  given.  Early  rupture  of  the  membranes  is 
widely  emplo}'ed  in  the  treatment  of  ablatio  placentae,  but  there  is 
little  doubt  that  the  results  following  its  application  are  not  such 
as  to  justify  its  routine  use.  Holmes  has  examined  a  large  number 
of  case  reports,  and  has  found  that  in  a  considerable  percentage 
hemorrhage  was  not  at  all  checked  or  only  partially.  It  cannot 
be  relied  upon  with  the  certainty  that  exists  in  cases  of  placenta 
prsevia. 

The  vaginal  tampon  has  been  considered  b}-  many  to  have  no 
place  in  the  treatment  of  ablatio  placentae,  but  to  be  of  much  value 
in  cases  of  placenta  previa.  Attention,  however,  should  be  called 
to  the  reports  of  Smyly  and  Tweedy  as  to  the  value  of  vaginal 
plugging  combined  with  firm  bandaging  of  the  abdomen  and 
perineum.  They  do  not  recommend  the  method  in  concealed 
hemorrhage,  nor  after  the  membranes  have  ruptured.  The 
vagina  should  be  packed  with  a  large  number  of  sterile  cotton- 
wool plugs.  Colclough,  in  speaking  of  this  method,  advises 
that  when  the  pains  have  been  very  vigorous  for  a  time  a  few 
of  the  plugs  should  be  removed  from  the  vagina.  At  Dublin, 
in  the  Rotunda,  this  method  is  now  the  routine  treatment  for 
marked  external  accidental  hemorrhage,  especially  in  cases  in 
which  the  pains  are  not  vigorous  and  the  os  not  well  dilated. 
Colclough  reports  that  hemorrhage  was  successfully  controlled 
in  42  out  of  43  cases. 

In  all  cases  after  extraction  of  the  fetus  the  placenta  and 
membranes  should  be  immediately  removed  by  the  introduction 
of  the  hand  into  the  uterus.  As  the  danger  of  postpartum  hem- 
orrhage is  great,  the  uterus  should  be  at  once  tamponed,  and  the 
organ  should  be  massaged  through  the  abdominal  wall  an  hour 
or  more.  Large  doses  of  ergot  should  be  given  with  a  hypo- 
dermic needle. 

As  regards  the  relative  merits  of  expectant  measures  and 
artificial  interference,  von  Weiss,  from  his  study  of    106   cases. 


POSTPARTUM  HEMORRHAGE.  565 

states  that  the  former   has  a  mortahty  of  74  per  cent.,  and  the 
latter  one  of  30  per  cent. 

(Caesarean  section  has  been  recommended  by  some  in  cases  of 
extreme  loss  of  blood.  Such  a  procedure  might  be  justifiable 
if  the  patient  were  in  such  a  position  as  to  be  operated  upon 
immediately,  rapidly,  and  aseptically,  but  under  no  other  circum- 
stances.) 

HEMORRHAGE  DURING  THE  THIRD  STAGE. 

Normally  in  labor  slight  hemorrhage  is  frequent  after  the 
birth  of  the  child,  as  a  result  of  laceration  of  the  perineum,  vagina, 
or  cervix.  The  amount  varies  greatly  in  different  cases.  Some- 
times it  is  considerable  ;  occasionally  excessive.  When  the  vagina 
is  badly  torn  there  may  be  an  alarming  flow,  owing  to  the  opening 
of  enlarged  veins  in  the  paravaginal  tissue.  In  other  cases  hem- 
orrhage may  proceed  from  the  interior  of  the  uterus,  when  the 
placenta  is  separated  entirely  or  partly  and  not  expelled,  owing  to 
uterine  inertia,  irregular  contractions  and  retraction,  or  to  adhe- 
sions between  the  placenta  and  uterus.  Bleeding  may  also  be  due 
to  rupture  or  inversion  of  the  uterus,  as  well  as  to  new  growths  in 
the  genital  tract.  It  is  important  that  the  source  of  the  bleeding 
should  be  definitely  located  in  each  case.  This  can  only  be  done 
by  systematic  examination.  The  signs  found  in  the  above-men- 
tioned conditions  are  given  where  the  latter  are  individually  de- 
scribed, the  appropriate  treatment  being  also  considered. 

POSTPARTUM  HEMORRHAGE. 

Bleedmg  from  any  part  of  the  genital  tract  may  be  included 
under  the  term  postpartum  hemorrhage.  In  the  present  connec- 
tion it  is  restricted  to  the  cases  in  which  the  blood  flows  from  the 
cavity  of  the  uterus,  after  the  birth  of  the  placenta,  within  the  first 
six  hours  following  labor.  This  complication  of  labor  is  fre- 
quently due  to  mismanagement  on  the  part  of  the  medical 
attendant.  When  the  hemorrhage  is  excessive  the  results  to  the 
patient  may  be  very  serious.  It  always  demands  prompt  and 
energetic  treatment. 

Ktiology. — The  most  important  alteration  that  is  associated 
with  postpartum  hemorrhage  is  absence  or  diminution  of  the  con- 
traction and  retraction  that  are  normally  present  in  the  uterus 
after  the  expulsion  of  its  contents,  and  which  exercise  an  im- 
portant influence  in  checking  the  flow  of  blood  through  the 
uterine  wall,  and  consequently  from  the  opened  sinuses  in  the 
placental  area. 

All  causes  of  uterine  inertia  or  atony,  therefore,  favor  post- 
partum hemorrhage.  Thus,  it  may  occur  after  prolonged,  dif- 
ficult, or  rapid  labors,  or  in  cases  in  which  there  has  been  unusual 


566  _^  COMPLEX  LABOR. 

enlargement  of  the  uterus — e.  g.,  multiple  pregnancy  or  hydram- 
nios.  Prolonged  anesthesia  and  certain  constitutional  conditions 
— c.  g.,  anemia,  Bright's  disease,  heart  disease,  hemophilia,  tuber- 
culosis, obesity,  and  general  weakness — favor  hemorrhage.  It 
occurs  more  frequently  in  multiparse  than  in  primiparae,  a  rapid 
succession  of  labors  being  particularly  favorable,  owing  to  weak- 
ness of  the  uterine  wall  from  overwork  of  the  muscle  and  excess 
of  connective  tissue ;  sometimes  paralysis  of  the  placental  part  of 
the  wall  may  be  a  cause.  All  conditions  that  prevent  the  uterus 
from  sinking  into  the  pelvis  and  acting  as  a  ball-plug  favor  bleed- 
ing— c.  g.,  distended  bladder  or  rectum  and  ovarian  or  other 
tumors.  Uterine  fibroids  may  prevent  the  uterus  from  sinking, 
but  they  may  directly  prevent  proper  uterine  contraction  and 
retraction.  A  contracted  pelvis  ma}'  not  allow  the  normal  descent 
and  so  may  favor  hemorrhage.  In  an  enlarged  pelvis  the  uterus 
may  descend,  but  does  not  act  as  a  plug,  and,  therefore,  favors 
hemorrhage.  Sudden  emotional  excitement  may  cause  relaxa- 
tion of  the  uterus.  Hemorrhage  may  follow  retention  of  part 
of  the  placenta,  membranes,  or  blood-clots.  It  is  favored  by  a 
low  implantation  of  the  placenta  (placenta  praevia). 

Diagnosis. — Bleeding  may  take  place  slowly  and  gradually, 
the  clothes  around  the  patient  becoming  soaked,  her  attention 
being  thus  called  to  the  condition.  In  some  cases  it  is  profuse  and 
escapes  in  rapid  gushes,  with  or  without  clots.  Frequently,  when 
the  latter  are  formed  in  the  uterus,  its  efforts  to  expel  them  cause 
pains  in  the  abdomen,  usually  in  the  loins,  and  these  may  first 
attract  attention  to  the  hemorrhage.  Generally,  however,  the 
patient's  condition  indicates  the  loss  of  blood.  She  grows  paler, 
the  skin  becoming  waxy  in  extreme  cases,  and  sometimes  cold 
and  clammy.  Respirations  may  be  rapid  and  shallow,  and  yawn- 
ing ma\'  be  a  noticeable  feature.  She  may  complain  of  faintness 
and  indistinctness  of  vision.  The  pulse  becomes  rapid  and  feeble. 
These  signs  may  be  present  though  little  external  bleeding  has 
occurred,  hemorrhage  taking  place  into  the  uterine  cavity  and 
vagina,  or  into  the  former  only  ;  in  these  cases  a  free  escape  of 
serum  through  the  vulva  may  be  noted.  In  other  cases  there 
may  be  considerable  combined  external  and  internal  loss.  In 
fatal  cases  convulsions  and  loss  of  consciousness  supervene.  The 
amount  of  blood  that  a  woman  can  lose  without  danger  varies 
according  to  a  number  of  conditions,  among  which  the  general 
health  is  an  important  factor.  Physiologists  have  stated  that  one- 
third  of  the  blood  may  be  lost,  in  a  healthy  woman,  without  risk 
of  death. 

On  palpating  the  abdomen  the  body  of  the  uterus  may  be  felt 
enlarged  as  high  as  or  higher  than  the  umbilicus ;  in  the  worst 
cases  of  internal  hemorrhage  it  may  occupy  a  large  area  of  the 
abdomen.      Frequently  its   outline   is   indefinable,   owing   to   the 


POSTPARTUM  HEMORRHAGE.  567 

softness  of  its  wall.  Indeed,  it  may  be  palpated  only  when  it 
makes  an  effort  at  retraction  or  contraction.  Some  degree  of 
hardening  may  be  noted  as  a  result  of  the  stimulus  of  palpation. 
In  the  majority  of  cases  in  which  there  is  marked  external 
hemorrhage  along  with  internal  accumulation,  the  uterus  does 
not  reach  the  size  usually  found  when  there  is  mainly  internal 
bleeding.  Very  rarely  uterine  hemorrhage  occurs  with  a  consid- 
erable degree  of  retraction  and  contraction  in  the  uterus.  In 
such  cases  the  blood  chiefly  comes  from  a  torn  cervix,  or  from 
that  part  of  the  lower  uterine  segment  that  has  not  undergone 
retraction  and  has  been  torn,  or  which  has  been  the  site  of  a  pla- 
centa prsevia. 

Hemorrhage  from  the  uterine  cavity  must  be  diagnosed  from 
that  due  to  the  laceration  of  the  cervix,  vagina,  or  perineum,  from 
a  ruptured  varicose  vein,  a  new  growth,  or  a  ruptured  hematoma. 
In  these  conditions  the  uterus  should  be  retracted  and  contracted  ; 
the  exact  source  of  the  bleeding  may  sometimes  be  determined 
only  by  careful  examination  of  the  lower  genital  tract. 

Prognosis. — Marked  loss  of  blood  following  labor  must  ever 
be  considered  as  a  grave  occurrence.  It  is  impossible  to  estimate 
the  amount  poured  out  in  any  case.  But  the  seriousness  of  a 
case  must  be  judged  not  by  the  actual  quantity  of  blood  lost,  but 
by  the  woman's  condition.  As  has  been  stated,  that  which  may 
be  a  dangerous  loss  for  one  may  scarcely  affect  another.  The 
general  health  is  an  important  consideration  ;  thus,  those  who  are 
already  anemic,  or  weakened  by  previous  disease  or  an  exhausting 
labor,  cannot  afford  to  lose  much  blood.  When  death  does  not 
occur  the  patient  may  remain  very  weak,  even  months  after  labor. 
Septic  infection  may  more  readily  take  place.  She  may  be  too 
feeble  to  nurse  her  child. 

Treatment. — Prophylaxis. — It  cannot  be  too  strongly  em- 
phasized that  postpartum  hemorrhage  is  almost  always  due  to  the 
careless  or  wrong  conduct  of  labor  on  the  part  of  the  medical 
attendant.  Remembering  that  uterine  inertia  is  the  most  impor- 
tant factor  in  its  production,  all  the  conditions  that  may  lead  to 
this  complication  must  be  prevented. 

Too  prolonged  a  first  stage  in  cases  of  slow  and  difficult  dila- 
tation, causing  general  exhaustion  and  uterine  weakness,  should 
not  be  permitted.  Neither  should  there  be  too  great  delay  in  the 
second  stage.  When  artificial  delivery  is  carried  out,  extraction 
must  not  be  too  rapid ;  in  these  cases  it  is  advisable  that  the  hand 
of  an  assistant  should  be  kept  on  the  fundus  of  the  uterus,  causing 
it  to  follow  the  descending  fetus. 

In  cases  of  hydramnios  the  liquor  amnii  should  be  slowly 
evacuated.  In  a  twin  labor,  after  the  first  child  is  born,  there 
should  not  be  too  much  hurry  in  the  delivery  of  the  second.  At 
the  end  of  the  second  stage  a  hand  should  be  kept  on  the  abdominal 


568  ^  COMPLEX  LABOR. 

wall  over  the  fundus  until  the  placenta  is  delivered,  and  sometime 
afterward.  In  this  position  the  condition  of  the  uterus  may  best 
be  determined  and  deviations  from  the  normal  be  corrected.  In 
many  cases  no  manipulations  are  necessary,  the  third  stage  being 
completed  normall}',  the  hand  simply  covering  the  fundus,  ready 
to  act  when  necessary.  This  stage  must  not  be  hurried.  Early 
forcible  compression  of  the  uterus,  while  the  placenta  is  still  at- 
tached, for  the  purpose  of  hastening  the  deliver^%  is  bad  practice 
save  where  there  is  some  distinct  indication  for  its  employment. 

Undue  relaxation  of  the  uterus  is  checked  by  massage  of  the 
fundus,  one  or  both  hands  grasping  it  anteroposteriorly.  After 
the  third  stage  is  finished  the  fundus  should  be  held  twenty  or 
twenty-five  minutes  in  normal  cases,  and  an  hour  or  more  in  those 
in  which  there  is  a  distinct  possibility  that  uterine  inertia  might 
.  supervene  ;  in  the  latter  ergot  may  be  administered.  The  placenta 
should  be  carefully  examined  as  soon  as  expelled,  and  if  an}'  portion 
has  been  left  in  the  uterus  this  should  at  once  be  removed.  When 
the  hand  is  removed  from  the  fundus  a  firm  abdominal  binder 
should  be  applied.  Additional  stimulation  of  the  uterus  ma)'  be 
obtained  if  three  folded  towels  be  placed  under  the  binder,  above 
the  fundus  of  the  retracted  and  contracted  organ. 

Active  Treatment. — Of  great  value  in  promoting  retraction 
and  contraction  of  the  relaxed  uterus  is  massage  of  the  organ 
through  the  abdominal  wall.  It  should  be  grasped  anteropos- 
teriorly with  one  or  both  hands  and  compressed  or  massaged. 
These  manipulations  are  usually  sufficient  to  expel  blood  and  clots 
from  the  uterine  cavity.  Sometimes  they  fail  to  do  this,  and  it  is 
necessary  to  introduce  a  hand,  carefully  sterilized  (a  boiled  rubber 
glo\'e  gives  the  best  protection),  for  the  purpose  of  removing  the 
clots  (and  any  retained  portions  of  the  placenta  and  membranes). 
The  intra-uterine  manipulations  sen,'e  also  as  an  additional  stimulus 
to  the  uterus.  Before  the  introduction  of  the  hand  the  external 
genitals  should  be  thoroughly  cleansed.  The  organ  should  then 
be  compressed  externally  and  pushed  well  down  into  the  pelvic 
cavity.  Arendt  has  advised  grasping  the  anterior  and  posterior 
lips  of  the  cervix,  in  order  to  pull  the  latter  well  dow^n  toward  the 
vulva ;  this  traction  helps  to  check  the  flow  of  blood  through  the 
uterine  arteries.  If  employed  alone,  however,  it  is  efficacious  only 
for  a  ver}^  short  time. 

In  addition  to  these  measures,  intra-uterine  irrigation  with  hot 
sterile  water  (120°  F.)  through  a  large  long-curved  double  cath- 
eter is  widely  recommended.  If  the  temperature  cannot  be  meas- 
ured with  a  thermometer,  it  may  be  roughly  estimated  by  pouring 
some  of  the  water  on  the  back  of  the  hand,  which  should  just  be 
able  to  bear  the  heat.  Care  should  be  taken  not  to  introduce  too 
hot  water,  lest  the  tissue  be  damaged.  If  the  fluid  be  not  hot 
enough  it  does  not  stimulate  the  uterus   to  contract,  but  rather 


POSTPARTUM  HEMORRHAGE.  569 

favors  bleeding.  In  beginning  the  injection  air  may  easily  be 
carried  into  the  uterine  cavity  and  give  rise  to  air  embolism.  The 
water  should,  therefore,  be  allowed  to  run  through  the  catheter 
before  it  is  introduced.  While  the  stream  flows,  there  should  be  a 
good  return  current;  if  this  be  prevented  the  uterus  may  be  dis- 
tended by  the  fluid.  According  to  Helme's  experiments,  the 
duration  of  the  hot  douche  should  not  exceed  two  minutes  ;  be- 
yond this  the  effect  is  to  raise  the  temperature  of  the  uterine 
musculature,  to  enfeeble  its  contractions,  and  make  them  irregular. 

The  application  of  ice  to  the  abdomen  and  vulva  has  long  been 
practised  in  cases  of  hemorrhage,  but  its  influence  cannot  be  com- 
pared to  that  of  the  manipulations  already  described.  Helme  has 
studied  the  effects  of  the  intra-uterine  cold  douche  (40°  to  50°  F.), 
and  points  out  that  it  produces  an  immediate,  powerful,  and  pro- 
longed tetanus-Hke  contraction  of  the  uterus,  a  marked  influence 
being  also  exerted  on  the  walls  of  the  blood-vessels.  If,  however, 
the  cold  douche  be  too  long  continued,  paralysis  of  the  muscula- 
ture may  follow  ;  the  duration  should  not  be  longer  than  two  or 
three  minutes.  Helme  is  of  the  opinion  that  the  cold  douche  is 
better  than  one  of  hot  water  for  the  purpose  of  immediately  check- 
ing postpartum  hemorrhage.  These  views  differ  from  those  of 
Milne  Murray,  who  has  also  worked  experimentally  at  the  subject. 
He  holds  that  the  hot  douche  is  more  desirable,  producing  greater 
rapidity  of  action  and  greater  duration  of  contraction,  while  it 
warms  and  stimulates  the  patient  and  does  not  abstract  heat  from 
her  tissues. 

Packing  of  the  uterine  cavity  is  a  very  valuable  method  of 
checking  hemorrhage,  the  uterine  musculature  being  stimulated, 
while  thrombosis  in  the  open  sinuses  is  favored.  When  the  tampon 
is  in  position,  external  manipulations  of  the  uterus  through  the 
abdominal  wall  may  be  more  effectively  employed.  The  best  tampon 
is  a  long  strip  of  sterile  or  antiseptic  gauze.  In  my  own  practice 
I  employ  chinosol  gauze,  iodoform  gauze  not  being  desirable,  on 
account  of  the  risk  of  toxic  phenomena  from  absorption  of  the 
drug.  To  introduce  the  tampon  the  patient  should  be  placed  in 
the  lithotomy  position,  and  the  external  genitals  cleansed  and  pro- 
tected by  sterile  coverings.  The  vagina  should  be  opened  with 
retractors  and  the  cervix  steadied  with  a  volsella ;  at  the  same 
time  the  body  of  the  uterus  should  be  compressed  and  steadied 
through  the  abdominal  wall  by  the  hands  of  an  assistant.  The 
gauze  should  then  be  packed  firmly  in  the  uterus,  the  lower  end 
passing  through  the  cervix  into  the  vagina.  Rudolph  Holmes 
has  devised  an  instrument  by  which  the  introduction  of  the  gauze 
is  facilitated.  It  consists  of  a  long  tube,  meant  to  enter  the  uterus, 
the  gauze  being  pushed  through  it  by  a  long  steel  rod,  the  tube 
being  gradually  withdrawn.  In  every  case  of  marked  hemorrhage 
the  intra-uterine  tampon  should  be  employed.     It  may  safely  be 


570  COMPLEX  LABOR. 

left  in  position  for  twenty -four  hours.  Several  authors  advise  that 
in  cases  of  marked  hemorrhage  absorbent  gauze  should  not  be 
used,  because  it  acts  as  a  drain  for  blood  and  serum.  Schaeffer 
has  recommended  a  non-absorbent  gauze,  prepared  by  impreg- 
nating it  with  gutta-percha. 

Ergot  is  widely  employed  for  the  purpose  of  checking  bleed- 
ing. Its  effects  on  the  uterus  have  been  studied  chiefly  by  Nikitin, 
Marckwald,  and  Helme.  Marckwald  showed  that  ergot  is  valuable 
in  producing  uterine  contractions,  but  has  very  little  influence  in 
checking  the  flow  of  blood  through  the  arteries.  Of  its  two 
chief  constituents,  ergotinin  has  no  effect  on  uterine  contractions 
and  increases  the  flow  of  blood  through  the  arteries,  sclerotic  acid 
increasing  uterine  contractions  and  diminishing  the  flow  through 
the  arteries.  The  ergotinin  and  sclerotic  acid,  therefore,  seem 
to  antagonize  each  other  as  regards  the  influence  on  arteries, 
though  the  action  of  the  latter  is  slightly  greater  than  that  of  the 
former.  Ergotinin  alone  is,  therefore,  of  no  value  in  checking 
hemorrhage.  Helme  has  corroborated  Marckwald's  results.  He 
points  out  that  the  larger  the  dose  of  ergot,  the  greater  the  in- 
tensity and  duration  of  the  individual  contractions  of  the  uterus, 
rhythmic  action  being  preserved  and  no  tendency  to  true  tetanus 
being  noted.  In  obstetric  work  hermetically  sealed  bulbs  of 
aseptic  ergot  are  reliable  long  after  they  are  prepared.  In  ordinaiy 
bottles  the  ergotin  decomposes  in  a  short  time.  Chloral  has  been 
used  as  a  preservative,  but  Helme  has  shown  that  it  is  inefficacious 
for  more  than  a  week  ;  moreoxer,  it  tends  to  diminish  uterine 
contractions  as  well  as  to  dilate  vessels.  In  all  cases  where  rapid 
action  of  the  ergot  is  needed  the  drug  should  be  injected  into 
muscle. 

Compression  of  the  abdominal  aorta  against  the  spine  may  be 
advantageously  employed  in  all  bad  cases  in  addition  to  other 
measures.  This  is  not  only  beneficial  in  checking  the  flow  of 
blood  through  the  uterus,  but  also  in  stimulating  the  uterus  to 
immediate  contraction,  as  Helme  has  demonstrated  experimen- 
tally. Strong  styptics — c.  g.,  perchlorid  of  iron — should  never  be 
employed  for  the  purpose  of  checking  postpartum  uterine  bleed- 
ing. These  fluids  may  enter  the  veins,  and  they  destroy  a  large 
quantity  of  tissue  on  the  inner  wall  of  the  uterus,  thereby  pro- 
ducing a  condition  of  the  parts  favorable  to  microbic  growth  if 
infection  should  occur.  Faradic  electricity  applied  to  the  uterus 
through  the  abdominal  wall  is  a  valuable  stimulus  to  uterine  con- 
traction, but  it  is  rare  that  a  battery  is  at  hand  when  it  is  needed 
in  these  cases. 

In  addition  to  the  local  measures  just  described,  it  is  important 
in  all  cases  in  which  much  blood  is  lost  to  employ  the  following 
means  for  the  purpose  of  counteracting  the  effects  of  the  acute 
anemia:  The  foot  of  the  bed  should  be  elevated  I2  in.  or  more. 


RETAINED   PLACENTA.  5/1 

A  pint  of  hot(iio°  F.)  normal  saline  solution  should  be  intro- 
duced into  the  bowel  through  a  long  rectal  tube,  in  order  that 
absorption  may  take  place,  the  volume  of  fluid  circulating  in  the 
vessels  increased,  and  the  body  temperature  raised.  This  should 
be  repeated  in  thirty  to  sixty  minutes  and  again  in  four  or  five 
hours.  If  this  be  not  retained,  a  subcutaneous  injection  (iio°  F.) 
may  be  given  under  each  breast.  In  extremely  acute  cases,  where 
the  danger  of  death  is  imminent,  an  arm  and  an  opposite  leg  may 
be  elevated  and  bandaged  from  their  extremities  to  the  trunk,  in 
order  temporarily  to  increase  the  quantity  of  blood  circulating 
in  the  head  and  trunk.  After  thirty  minutes  the  bandages  may 
be  loosened  if  abundant  saline  solution  has  been  introduced  into 
the  system,  and,  if  necessary,  the  other  arm  and  leg  may  be 
similarly  treated.  In  bad  cases  it  is  also  advisable  to  apply  heat 
to  the  exterior  of  the  body  by  means  of  hot-water  bottles.  It 
may  be  necessary  to  give  cardiac  stimulants  hypodermically.  As 
soon  as  the  patient  can  retain  fluid  in  her  stomach,  hot  strong 
coffee,  hot  milk,  or  hot  brandy  and  water  may  be  given  repeatedly 
in  small  doses. 

In  the  convalescent  stage  the  patient  should  remain  in  bed 
longer  than  the  normal  period  ;  in  bad  cases  at  least  a  month. 
Nursing  should  be  prohibited.  Careful  medicinal  and  dietetic 
measures  should  be  employed  to  build  up  the  blood.  The  in- 
creased risk  of  infection  should  be  remembered,  and  if  there  has 
been  any  imperfection  as  regards  asepsis  in  the  manipulations 
employed  in  the  genital  tract,  antiseptic  douches  should  be  freely 
used. 

(Secondary  postpartum  hemorrhage  will  be  considered  in  the 
chapter  dealing  with  the  Pathology  of  the  Puerperium.) 

RETAINED  PLACENTA. 

This  term  may  be  applied  to  conditions  in  which  the  placenta 
is  not  delivered  within  the  normal  period,  including  the  cases  in 
which  it  is  unseparated  or  partly  separated,  lying  in  the  upper 
uterine  segment ;  or  separated  and  lying  in  the  lower  segment 
and  cervix,  in  the  vagina,  or  in  all  three.  Many,  however,  restrict 
the  term  to  the  cases  in  which  it  is  in  the  upper  segment,  attached 
or  partly  separated. 

Causes. — When  the  placenta  is  separated,  but  remains  below 
the  upper  uterine  segment,  the  reason  for  the  failure  in  its  delivery 
is,  in  the  great  majority  of  cases,  faulty  action  of  the  accessory 
muscles,  often  associated  with  marked  stretching  of  the  linea  alba, 
the  voluntary  efforts  of  the  patient  being  insufficient  to  bring 
about  expulsion.  Very  rarely  is  the  placenta  firmly  held  by  an 
abnormally  contracted  cervix.  Occasionally  adhesion  of  the 
membranes  prevents  the  expulsion. 


572 


COMPLEX  LABOR. 


Retention  of  the  placenta  in  the  upper  segment  is  due  to 
inertia  of  part  or  the  whole  of  that  portion  of  the  uterus.  The 
inertia  may  be  due  to  constitutional  weakness,  prolonged  or  dif- 
ficult labor,  or  too  rapid  delivery.  It  may  also  be  due  to  the 
condition  of  the  uterus  described  as  "  hour-glass  contraction." 
This  is  simply  an  excessively  contracted  or  retracted  ring-like 
portion  of  the  uterine  wall  above  the  remains  of  the  lower  uterine 
segment ;  it  is,  indeed,  a  postpartum  retraction  ridge,  the  lower 
edge  of  the  upper  uterine  segment.  Below  this  ridge  the  lower 
segment  and  cervix  may  usually  be  felt  soft  and  flabby. 


Fig.  251. — Hour-glass  contraction  of  uterus.  The  contraction  is  due  to  abnormal 
development  of  the  retraction  ridge  below  the  placenta  :  a  a.  Internal  os  ;  b,  cervical 
cavity;  c  l\  external  os  (Bumm). 


Diagnosis. — As  long  as  the  placenta  remains  within  the 
upper  uterine  segment  the  body  of  the  uterus,  as  palpated 
through  the  abdominal  wall,  remains  as  large  as  it  was  imme- 
diately after  the  birth  of  the  fetus.  The  fundus  is  in  the  region 
of  the  umbilicus;  the  body  feels  somewhat  rounded,  the  retracted 
wall  being  firm,  usually  relaxing  and  hardening  at  intervals.  If 
intra-uterine  hemorrhage  occurs,  the  blood  being  retained,  the 
organ  may  be  much  enlarged  and  its   outline  may  become  inde- 


RETAINED   PLACENTA.  573 

finable;  in  this  condition  there  are  symptoms  of  anemia.  On 
internal  examination  the  placenta  may  be  felt  above  the  cervix 
and  lower  segment. 

When  the  placenta  is  held  partly  above  and  partly  below  the 
retraction  ridge,  the  body  of  the  uterus  may  be  felt  through  the 
abdominal  wall,  slightly  smaller  than  when  the  placenta  is  entirely 
in  the  upper  segment,  unless  blood  accumulates  in  the  latter.  On 
internal  examination  the  lower  portion  of  the  placenta  is  felt  below 
the  ridge,  while  the  latter  is  felt  firmly  holding  the  placenta. 

When  the  placenta  lies  below  the  upper  uterine  segment,  the 
latter,  if  firmly  contracted,  is  felt  hard  and  no  larger  than  it  is  in 
the  normal  early  postpartum  state.  It  is,  however,  much  higher 
above  the  pelvic  brim,  being  prevented  from  sinking  down  because 
of  the  retention  of  the  placenta.  On  internal  examination  the 
latter  is  easily  felt  in  the  cervix  or  upper  part  of  the  vagina. 

Treatment. — In  all  cases  of  retained  placenta  careful  exami- 
nation of  the  uterus  should  be  made  through  the  abdominal  wall, 
in  order  to  determine  the  procedure.  A  vaginal  examination  is 
rarely  necessary,  and  should  be  made  as  seldom  as  possible.  If 
the  bladder  contain  urine,  it  should  be  emptied  before  manipula- 
tions are  carried  out.  When  there  is  uterine  inertia,  catheterization 
may  be  followed  by  fresh  uterine  contractions.  If  the  examina- 
tion of  the  abdomen  proves  that  the  upper  uterine  segment  is 
empty,  the  uterus  should  be  grasped  with  one  or  both  hands  and 
pressed  downward  in  the  axis  of  the  pelvic  brim,  in  order  to  expel 
the  placenta.  As  the  latter  appears  at  the  vulva  it  should  be 
rotated,  the  membranes  being  thereby  twisted  into  a  rope,  so  as 
to  lessen  the  chance  of  tearing  them. 

When  the  placenta  lies  in  the  upper  segment,  the  uterine  body 
should  be  steadily  massaged  through  the  abdominal  wall.  If, 
after  ten  or  fifteen  minutes,  there  is  no  expulsion  of  the  placenta, 
the  upper  part  of  the  uterus  should  be  compressed  anteropos- 
teriorly,  not  forcibly,  but  cautiously.  If  this  fails  to  make  the 
placenta  descend,  no  further  efforts  of  this  kind  should  be  made. 
After  cleansing  the  patient's  external  genitalia  the  right  hand, 
thoroughly  sterilized,  should  be  introduced  in  the  shape  of  a  cone 
into  the  vagina  and  passed  through  the  cervix,  the  latter  being 
dilated,  if  necessary.  The  fingers,  placed  side  by  side,  are  then 
inserted  between  the  lower  edge  of  the  placenta  and  the  uterus 
and  moved  from  side  to  side,  so  as  to  bring  about  complete  sepa- 
ration. During  this  procedure  counterpressure  is  exerted  with 
the  other  hand  placed  on  the  abdominal  wall.  The  placenta  is 
gradually  withdrawn  by  the  hand  and  is  rotated  as  it  descends 
in  the  vagina,  so  as  to  twist  the  membranes  into  a  rope,  lessening 
the  chances  of  their  retention.  Immediately  afterward  the  pla- 
centa and  membranes  should  be  carefully  examined  in  sterile 
water.     If  a  portion  of  the  placenta  is  missing,  the  uterine  cavity 


574 


COMPLEX  LABOR. 


should  be  explored.  If  a  considerable  portion  of  membranes  be 
retained,  the  fingers  should  be  introduced  into  the  uterus  to 
extract  it.  When  there  is  marked  closure  of  the  retraction  ridge 
(so-called  "  hour-glass  contraction  "),  dilatation  must  be  carried 
out  by  the  fingers,  deep  anesthesia  usually  being  necessary. 

In  conclusion,  it  must  be  emphasized  that  internal  examination 
is  rarely  necessary  when  the  entire  placenta  is  retained,  since  a  diag- 
nosis may  almost  always  be  established  by  external  examination 


Fig.  252. — Method  of  separating  and  removing  placenta  by  introduction  of  hand  into 

uterus  (Bumm). 

if  the  anatomic  relationships  are  thoroughly  understood.  In  a 
i&vf  cases,  especially  those  complicated  by  hemorrhage,  internal 
examination  is  necessar\^ 

ADHERENT  PLACENTA. 
Occasionally  the  placenta  is  retained  in  the  uterus  because 
the  tissue  that  is  normally  torn  is  abnormally  firm.  It  must, 
however,  be  remembered  that  adherent  placenta  is  sometimes 
diagnosed  when  the  condition  does  not  exist,  the  retention  being 
due  to  other  causes. 


RUPTURE    OF   rilE    UTERUS.  575 

It  is  usually  said  that  the  causes  of  adherent  placenta  are 
inflammations  of  the  decidua  and  placenta.  It  is  very  doubtful, 
however,  if  inflammatory  changes  in  the  villi  ever  interfere  with 
the  delivery  of  the  placenta.  The  normal  separation  plane  is 
through  the  decidua,  and  it  is  likely  that  the  so-called  "  ad- 
hesions "  are  merely  portions  of  decidua  so  firm,  as  the  result 
of  inflammation,  that  they  are  not  torn  in  the  normal  manner. 
In  most  cases  it  is  probable  that  the  toughness  of  the  tissues  is 
due  to  an  old  inflammatory  process  that  existed  before  pregnancy, 
though  sometimes  it  may  be  induced  in  pregnancy — e.g.,  in  some 
forms  of  syphilis.  The  condition  is  met  with  in  different  forms. 
Rarely  the  tissues  are  so  extensively  altered  that  no  part  of  the 
placenta  separates.  Usually  only  one  or  more  portions  of  the 
decidua  are  affected,  partial  separation  taking  place.  The  adhe- 
sions are  much  firmer  in  some  cases  than  in  others. 

Diagnosis. — When  the  placenta  does  not  separate  at  all,  it 
remains  in  its  normal  position  in  the  upper  uterine  segment,  the 
uterus  being  retracted  around  it.  There  is  no  hemorrhage  from 
the  uterine  cavity.  If  attempts  are  made  to  expel  the  placenta 
by  moderate  compression  of  the  uterine  body,  they  are  ineffectual. 

When  the  placenta  is  partly  separated  in  its  lower  portion, 
hemorrhage  occurs  and  a  large  quantity  may  escape  through  the 
cervix ;  in  some  cases  the  loss  may  be  rapid  and  alarming. 

When  the  upper  part  of  the  placenta  is  separated,  very  little 
blood  may  be  poured  out,  and  it  may  accumulate  in  the  upper 
part  of  the  uterus,  very  little  escaping  through  the  cervix ;  in  some 
cases  a  considerable  quantity  may  escape. 

Treatment. — When  the  diagnosis  of  adherent  placenta  is 
made,  removal  by  intra-uterine  manipulations  is  necessary,  the 
fingers  being  used  in  the  manner  already  described  to  separate  the 
placenta.  In  some  cases  this  is  accomplished  with  difficulty,  and 
it  may  be  impossible  to  remove  the  placenta  without  tearing  it  and 
extracting  it  piece  by  piece.  The  procedure  should  be  followed  by 
very  thorough  washing  out  of  the  uterus  with  hot  normal  saline 
solution,  in  order  to  remove  loose  portions  of  tissue  and  blood-clot. 

With  regard  to  the  frequency  with  which  artificial  separation 
and  removal  of  the  placenta  are  necessary,  it  is  interesting  to  note 
Littauer's  statistics  of  10,978  labors  in  Leipzig.  He  found  that, 
excluding  placenta  praevia  cases,  it  was  practised  in  the  proportion 
of  I  in  186  labors  at  or  near  term,  or  i  in  161  including  prema- 
ture labors.  Honck,  of  Hamburg,  in  a  large  maternity  experience, 
had  a  proportion  of  i  in  365. 

RUPTURE  OF  THE  UTERUS. 

The  cervix  and  the  lower  and  upper  segments  of  the  uterus 
may  be  ruptured  in  connection  with  labor.  The  term  as  here  em- 
ployed signifies  the  condition  in  which  rupture  of  the  uterine  body 


57^  ^  COMPLEX  LABOR. 

is  the  predominant  lesion.  Reference  has  ah'eady  been  made 
to  its  occurrence  (rarely)  in  pregnancy  ;  in  the  great  majorit}' 
of  cases  the  lesion  is  related  to  labor.  While  in  pregnancy 
rupture  is  rarely  spontaneous,  in  cases  of  labor  the  majority  are 
of  this  nature.  According  to  Jolly,  in  573  cases,  376  were  spon- 
taneous and  197  traumatic. 

Etiology. — Certain  conditions  may  be  regarded  as  predis- 
posing. Thus,  rupture  is  more  frequent  in  multiparae  than  in 
primiparae,  the  proportion  being,  according  to  Bandl,  8  to  i.  Trask 
found  that  in  303  cases  there  were  only  24  primiparae,  while  Jolly 
noted  only  37  in  455  cases.  Very  frequent  child-bearing,  espe- 
cially if  the  pregnancies  succeed  one  another  closely,  leads  undoubt- 
edly to  a  deteriorated  condition  of  the  uterine  wall.  The  arteries 
and  veins  in  the  uterus  and  broad  ligaments  may  be  considerabh^ 
altered.  In  the  former  degeneration  maybe  present  in  the  intima  ; 
in  the  veins  dilatation  and  varicosity  are  present.  As  a  result  the 
nutrition  of  the  uterine  tissue  is  altered  and  it  is  more  readily  torn. 
There  is  an  increase  of  the  intermuscular  connective  tissue  that 
lessens  the  resistance  of  the  uterine  wall.  Chronic  inflammatory 
changes  in  the  wall  lessen  its  resiliency.  Abnormal  thinness  pre- 
disposes to  rupture  ;  this  may  be  due  to  hydramnios  or  multiple 
pregnancy ;  it  may  be  caused  by  a  fibroid  tumor  or  may  be  con- 
genital (/.  £.,  malformed  uterus), but  it  is  most  frequently  produced 
in  labor  b\'  conditions  shorth'  to  be  described.  Cicatrices  follow- 
ing a  previous  rupture  or  a  Caesarean  section  are  weak  areas.  The 
lower  uterine  segment  is  more  easily  torn  in  cases  of  placenta 
praevia  than  in  normal  cases.  The  wall  may  be  weakened  by 
fatty  degeneration  or  by  carcinoma.  In  a  few  cases  of  spon- 
taneous rupture  early  in  labor  the  cause  of  the  friable  uterus 
can  not  be  determined.  When  the  cervix  is  very  rigid,  so 
that  it  will  not  dilate  easily,  or  when  it  is  the  seat  of  a  tumor, 
there  is  increased  risk  of  rupture.  All  forms  of  contraction  of 
the  hard  passages  that  interfere  with  the  normal  action  of  the 
uterus  in  labor  and  with  the  descent  of  the  child  are  predisposing 
factors.  Similarly,  any  narrowing  of  the  soft  canal  due  to  con- 
genital defects,  cicatricial  contractions,  or  the  pressure  of  tumors 
and  other  swellings,  are  favoring  conditions.  Rarely  rupture 
follows  thinning  of  the  wall  in  hydatidiform  degeneration  of  the 
chorion.  On  the  part  of  the  fetus  must  be  mentioned  excessive 
size,  deformities  of  parts — l\  g-.  hydrocephalus  or  monstrosity,  mal- 
positions and  malpresentations — e.g.,  transverse.  Rupture  is  more 
frequent  with  male  than  with  female  children. 

The  exciting  or  determining  causes  of  rupture  in  labor  are  as 
follows  :  Rarely  there  is  some  form  of  external  traumatism — c.  g., 
a  fall  or  blow.  The  most  frequent  form  of  traumatism  is  that  re- 
sulting from  attempts  at  delivery  on  the  part  of  the  accoucheur — - 
z.  e.,  performing  version  or  using  instruments.    The  administration 


RUPTURE    OF   THE    U7ERUS.  577 

of  ergot  in  delayed  labor  may  cause  rupture  of  the  lower  uterine 
segment  by  inducing  excessive  contractions  in  the  upper  segment. 
Sometimes  the  wall  may  rupture  as  the  result  of  long-continued 
pressure  between  the  fetus  and  the  bony  wall  of  the  pelvis.  In  a 
very  large  percentage  of  cases  spontaneous  rupture  takes  place  as 
a  result  of  extreme  retraction  of  the  upper  uterine  segment,  the 
lower  segment  being  stretched  and  thinned  over  the  presenting 
portion  of  the  fetus. 

The  differentiation  of  the  uterine  wall  in  labor  has  already  been 
fully  considered.  (See  p.  i6o.)  It  has  been  pointed  out  that  the 
retraction  ridge  which  extends  around  the  wall  of  the  uterus  is  the 
lower  boundary  of  the  upper  thick  active  segment,  that  part  of 
the  uterine  wall  below  it  being  thin  and  to  a  large  extent  inactive 
in  labor.  When  labor  is  obstructed  from  any  of  the  causes  enu- 
merated above  and  the  upper  segment  continues  to  be  active, 
excessive  retraction  accompanied  by  contractions  results  in  the 
elevation  of  the  retraction  ridge,  while  the  lower  segment  thins  and 
stretches  and  may  at  length  rupture.  In  almost  all  cases  this 
occurs  after  the  membranes  have  burst.  While  it  is  probable  that 
as  long  as  these  are  intact  the  danger  of  uterine  rupture  is 
lessened,  it  must  be  remembered  that  occasionally  this  lesion 
may  take  place  before  the  liquor  amnii  has  escaped.  Occasion- 
ally spontaneous  rupture  of  a  friable  uterus  may  occur  early 
in  labor,  before  the  retraction  ring  is  well  differentiated,  when  the 
cervix  is  not  abnormally  rigid.  Such  cases  have  been  reported  by 
A.  R.  Simpson  and  Milne  Murray. 

Frequency. — Statistics  as  to  the  frequency  of  rupture  of  the 
uterus  vary  greatly.  Though  it  is  not  so  common  as  in  the  pre- 
anesthesia  days,  it  is  probably  more  frequent  than  is  generally 
believed.  It  is  extremely  rare  in  labors  conducted  by  skilled  ob- 
stetricians, and  is  generally  found  in  the  practice  of  midwives  and 
unskilled  practitioners.  It  is  more  common  in  districts  where 
marked  pelvic  deformities  are  found.  A  few  of  the  statistics  are 
as  follows  :  Koblanck's,  i  in  462  labors  ;  Winckel's,  i  in  666  labors  ; 
Bandl's,  i  in  1200  labors;  Jolly's,  i  in  3403  labors. 

Pathologic  Anatomy. — ^Rupture  may  be  found  in  any  part 
of  the  uterine  wall.  This  is  especially  the  case  when  the  rent  is 
due  to  external  injury — e.  g.,  a  fall — to  a  new  growth  causing  thin- 
ning, or  to  the  tearing  of  an  old  cicatrix.  In  the  great  majority 
of  instances,  however,  it  is  the  lower  uterine  segment  that  is 
affected.  Ruptures  are  described  as  complete  when  the  whole 
wall  is  torn  so  that  a  communication  is  established  between  the 
uterine  and  the  peritoneal  cavities.  The  rupture  varies  in  size, 
shape,  and  direction  ;  it  may  admit  the  passage  of  one  or  two 
fingers  or  of  one  or  two  hands.  The  openings  caused  by  pressure- 
necrosis  are  usually  small  and  rounded  ;  they  maybe  opposite  the 
promontory,  top  of  the  symphysis,  or  an  exostosis.     Generally  the 

Z7 


578 


COMPLEX  LABOR. 


rupture  is  an  irregular  slit.  It  maybe  vertical,  oblique,  or  trans- 
verse; straight,  curved,  irregular,  zigzag,  stellate,  T-shaped,  L- 
shaped,  etc.  Rarely  it  is  circular,  involving  almost  the  whole  cir- 
cumference of  the  lower  uterine  segment ;  in  this  condition  the 
main  portion  of  the  uterus  may  rise  in  the  abdomen.  The  edge 
of  the  rent  is  usually  irregular  and  rough,  somewhat  contused  and 
swollen,  and  infiltrated  with  blood.  Where  there  has  been  much 
pressure  against  the  bony  wall  the  tissue  may  be  somewhat 
necrotic.  The  peritoneum  is  loose  around  the  rent  and  separated 
to  a  greater  or  less  extent ;  effused  blood  may  burrow  under  it, 
forming  a  clot.  Rupture  most  frequently  occurs  on  the  left  side. 
It   is   generally  single,  but  sometimes  the  wall   may  be  torn  in 

different  places.  With  a  complete 
tear  there  may  be  one  or  more 
incomplete  rents. 

The  fetus  usually  dies  when 
there  is  a  well-marked  rupture. 
Sometimes  it  remains  entirely 
within  the  uterus.  When  the  rup- 
ture is  large,  it  generally  passes 
partly  or  entirely  into  the  peritoneal 
ca\it}'.  In  the  latter  instance  it  may 
lie  close  to  the  uterus  or  at  some 
distance  from  it,  among  the  intes- 
tines. The  uterus  may  remain  re- 
laxed after  the  escape  of  the  fetus, 
but  it  may  retract  more  or  less 
firmly.  The  placenta  may  remain 
in  the  uterus,  separated  or  not,  or 
may  pass  partly  or  entirely  into  the 
peritoneal  cavity.  Rarely  it  may  pass 
through  the  rupture,  the  fetus  remaining  in  the  uterus.  Stoltz  has 
reported  a  case  in  which,  in  advanced  gestation,  a  rupture  of  the 
uterus  occurred,  extending  from  the  fundus  to  the  cervix,  through 
which  the  entire  ovum  escaped,  with  unbroken  membranes,  into  the 
peritoneal  cavity.  Blood  escapes  among  the  intestines  in  var}'ing 
quantities,  usualh*  mixed  with  liquor  amnii.  In  cases  in  which  the 
cervix  has  been  dilated  and  the  membranes  ruptured  micro-organ- 
isms may  enter  the  uterus  and  peritoneal  cavity,  especially  if  labor 
has  been  protracted  or  has  been  conducted  in  a  dirty  manner.  De- 
composition and  septic  infection  may  follow,  in  connection  with 
which  emph}'sematous  changes  may  take  place  in  the  fetal  and  ma- 
ternal tissues  ;  escaped  blood  maybe  entirely  fluid  or  partly  coagu- 
lated. Through  the  rupture  intestines  may  enter  the  uterine 
cavity,  though  this  cannot  take  place  to  any  marked  extent  when 
the  uterus  retracts  well,  as  it  often  does  after  the  escape  of  the 
fetus.     The  bowel  may  pass  as  low  as  the  vagina ;  sometimes  it 


Fig.  253. — Transverse  rupture  of 
lower  segment  of  uterus  (Spiegel- 
berg)  :  a.  Probe  inserted  under  the 
peritoneum. 


RUPTURE    OF   THE    UTERUS.  579 

becomes  strangulated.  The  rectum  is  rarely  ruptured  along 
with  the  uterus  ;  more  frequently  the  bladder  is  involved.  The 
cervix  and  vagina  may  also  be  imphcated. 

Incomplete  ruptures  are  usually  tho.se  in  which  the  mucosa 
and  musculature  are  more  or  less  divided,  the  peritoneal  coat 
being  intact.  The  peritoneum  around  the  rent  may  or  may  not 
be  dissected  away  and  bulged  out  by  blood-clot.  Sometimes  a 
very  large  subperitoneal  accumulation  may  form  and  may  burrow 
in  the  broad  ligaments,  iliac  fossae,  and  elsewhere.  Sometimes 
the  peritoneum  bursts  and  the  rupture  is  made  complete.  The 
fetus  may  remain  entirely  in  the  uterus,  or  part  of  it  may  pro- 
trude through  the  rent  and  lie  under  the  peritoneum.  Rarely  the 
placenta  may  escape  and  remain  in  the  latter  position. 

Another  form  of  incomplete  rupture  has  been  described — viz., 
that  in  which  the  serosa  and  part  of  the  musculature  are  divided. 
They  may  be  slight  or  extensive  and  may  involve  large  sinuses, 
leading  to  marked  escape  of  blood  into  the  peritoneal  cavity. 
They  may  be  found  on  any  part  of  the  uterus,  chiefly  in  the 
upper  portion. 

Symptoms  and  Physical  Signs. — In  the  majority  of  cases 
of  rupture  the  accident  is  preceded  by  chnical  conditions  that 
should  suffice  to  give  warning  of  the  threatening  danger.  Usually 
there  is  a  history  of  a  protracted  labor,  especially  after  dilatation 
of  the  cervix  and  rupture  of  the  membranes.  The  cause  of  delay 
should  have  been  recognized — ^-g-,  contracted  pelvis,  malpresenta- 
tion,  tumor,  etc.  There  may  have  been  marked  uterine  contrac- 
tions with  expulsive  efforts  on  the  part  of  the  accessoiy  muscles 
without  advance  of  the  fetus.  Increasing  abdominal  distress  or 
pain,  more  or  less  continuous,  may  be  present.  In  palpating  the 
uterus,  especially  above  the  pubes,  the  woman  complains  of  ten- 
derness. Through  the  stretched  lower  uterine  segment  the  fetus 
may  be  felt  with  great  distinctness  if  the  abdominal  wall  be  not 
too  fat.  Along  the  line  of  the  round  ligaments  there  is  increased 
resistance  and  soreness,  and  one  or  both  may  be  very  distinctly 
felt.  The  retraction  ridge  is  felt  to  rise  higher  and  higher  above 
the  symphysis,  and  may  be  felt  as  an  oblique  or  transverse  thick- 
ening, two  or  more  inches  above  the  pubes.  The  pulse  and 
temperature  usually  rise  and  the  patient  is  anxious  and  distressed. 
Rupture  usually  occurs  during  uterine  contraction  or  while  some 
manipulation  is  being  carried  out ;  it  may  be  accompanied  with 
great  pain  and  the  woman  may  have  a  sensation  of  tearing. 
Movements  of  the  fetus  and  contractions  of  the  uterus  cease,  and 
there  is  usually  a  feeling  of  relief,  succeeded  by  shock  and  signs 
of  hemorrhage,  and  often  dull  abdominal  distress.  Sometimes 
uterine  contractions  may  continue  for  a  little  while.  External 
bleeding  may  or  may  not  take  place.  The  woman  becomes 
greatly  collapsed  and  may  soon  die. 


580  COMPLEX  LABOR. 

The  appearance  of  the  abdomen  varies.  It  may  present  a 
uniform  roundness,  especially  when  much  blood  has  escaped 
into  the  cavity  and  the  intestines  have  been  floated  up  and  dis- 
tended. Sometimes  an  irregular  mass  is  visible,  consisting  of  the 
uterus  with  the  fetus  partly  delivered  through  the  rent  or  lying 
alongside  it.  Sometimes  the  uterus  may  form  a  marked  anterior 
projection,  the  fetus  lying  behind  it.  Palpation  usually  causes 
distress,  so  that  it  may  be  difficult  to  outline  the  parts.  The 
difficulty  is  increased  when  there  is  much  meteorism.  The  uterus 
varies  in  shape  and  size  according  to  whether  the  fetus  is  entirely 
within  it,  entirely  without,  or  partly  escaped  from  it.  In  the  first 
case  the  mass  is  large,  firm,  and  irregular,  the  uterine  wall  being 
moulded  on  the  fetus.  In  the  second  case  the  uterus  is  some- 
times soft  and  relaxed,  but  generally  retracted  and  somewhat 
firm,  lying  anterior  to  the  fetus  or  on  one  side.  When  the  fetus 
is  only  partly  escaped  through  the  rupture  the  whole  mass  is 
large  and  very  irregular.  It  is  rare  that  fluid  blood  can  be  de- 
tected by  palpation  and  percussion.  When  a  large  subperitoneal 
hematoma  is  formed  on  the  anterior  wall  of  the  uterus,  in  the 
broad  ligament,  or  in  the  iliac  fossa  it  may  be  palpated.  Fetal 
movements  and  the  fetal  heart  sounds  are  rarely  detected  after 
escape  from  the  uterus.  Emph}-sematous  crackling  may  some- 
times be  detected  at  the  seat  of  rupture  by  palpation. 

On  vaginal  examination  the  part  of  the  fetus  that  presented 
earlier  in  labor  is  found  to  have  moved.  No  portion  whatever 
may  be  felt  if  it  has  passed  completely  into  the  peritoneal  cavity. 
If  it  has  partly  escaped  it  ma)'  be  found  in  the  torn  rent.  The 
placenta  and  membranes  may  be  palpated,  the  former  separated 
or  not ;  abundant  blood-clots  may  be  present.  The  irregular 
edge  of  the  rupture  may  often  be  felt,  and  through  it  intestines 
may  sometimes  extend  into  the  uterus.  On  catheterizing  the 
bladder  no  urine  ma}-  be  obtained  if  the  rupture  has  extended 
into  the  viscus,  though  sometimes  bloody  fluid  may  be  present. 
Occasionally  blood  may  be  found,  though  no  rupture  exists ;  it 
probably  results  from  contusion  of  the  wall  in  labor. 

In  exceptional  cases  complete  rupture  may  not  be  associated 
with  the  above  distinctive  phenomena.  It  may  exist  without  in- 
terfering with  the  delivery  of  the  fetus  through  the  vagina.  The 
rupture  may  not  be  accompanied  with  pain,  hemorrhage,  or 
change  in  uterine  contractions.  These  are  usually  cases  in  which 
the  rent  is  not  large.  Sometimes  the  fetus  may  pass  into  the 
peritoneal  cavity,  causing  ver\'  little  shock,  hemorrhage,  or  pain, 
and  the  woman  may  not  be  able  to  state  the  time  of  its  occur- 
rence. 

In  incomplete  subperitoneal  rupture  the  symptoms  are  not  as 
marked  as  in  complete  rupture.  Uterine  contractions  may  cease 
sometimes,  but  they  may  continue,  though  considerably  modified. 


RUPTURE    OF   THE    UTERUS.  58 1 

The  fetus  does  not  escape  entirely  from  the  uterus.  It  may 
remain  within  the  cavity,  or  part  of  it  may  bulge  into  the  rent 
under  the  peritoneum.  Hemorrhage  is  usually  present,  varying 
in  amount  in  different  cases.  The  blood  escapes  to  the  exterior, 
but  may  accumulate  internally,  burrowing  under  the  peritoneum. 
The  symptoms  due  to  loss  of  blood  may,  therefore,  vary  consid- 
erably ;  they  are  rarely  of  the  worst  type. 

On  physical  examination,  when  the  fetus  remains  in  the  uterus, 
no  change  may  be  distinguished.  If  the  peritoneum  external  to 
the  rupture  is  bulged  by  a  hematoma,  the  swelling  may  be  pal- 
pated if  it  be  large  and  situated  laterally  or  anteriorly.  If  part  of 
the  fetus  bulges  into  the  rupture,  it  may  often  be  palpated  as  an 
irregular  projection  from  the  uterus  proper,  and  the  latter  may  be 
sometimes  correspondingly  reduced  in  size.  On  vaginal  examina- 
tion the  edges  of  the  rupture  may  frequently  be  palpated.  The 
peritoneum  may  sometimes  be  felt  as  an  unbroken  layer,  and  a 
blood-accumulation  may  be  outlined  when  situated  anteriorly  or 
laterally.  When  rupture  of  the  peritoneal  surface  of  the  uterus 
occurs,  there  is  no  external  hemorrhage,  and  no  rent  can  be  felt 
on  vaginal  examination.  The  symptoms  are  those  of  loss  of  blood 
internally,  and  they  vary  according  to  the  extent  of  the  hemor- 
rhage. 

Prognosis. — The  risks  to  the  mother  and  child  are  very  great 
in  complete  rupture  of  the  uterus.  The  child  dies  in  nearly  all 
cases,  death  being  due  to  asphyxia.  The  chief  danger  to  the 
mother  in  all  cases  are  primarily,  loss  of  blood,  and  secondarily, 
septic  infection.  The  risks  are  increased  by  prolapse  and  strangu- 
lation of  intestine  and  by  rupture  of  the  bladder.  In  subperitoneal 
rupture  the  risks  are  much  smaller.  The  mortality  is  much 
greater  in  cases  of  complete  rupture  when  surgical  treatment  is  not 
carried  out  than  when  it  is. 

Diagnosis. — The  diagnosis  of  rupture  is,  as  a  rule,  easy. 
When  the  condition  is  produced  slowly ;  when  the  loss  of  blood  is 
not  great ;  when  the  fetus  remains  in  the  uterus  and  the  contrac- 
tions of  the  latter  do  not  cease,  there  is  difficulty  in  being  certain 
as  to  whether  a  rupture  exists  or  whether  it  is  complete  or  incom- 
plete, especially  in  cases  where  there  is  a  normal  vertex  presenta- 
tion of  the  head. 

Rupture  of  the  uterus  must  be  diagnosed  from  placenta  praevia. 
In  the  latter  there  is  not  necessarily  any  abnormality  in  the  shape 
of  the  uterus  or  in  the  position  of  the  retraction  ring  ;  moreover, 
the  placenta  may  often  be  felt  on  vaginal  examination.  Occasion- 
Ally  in  rupture  of  the  uterus  the  placenta  is  detached  and  pro- 
lapsed ;  it  may  then  be  mistaken  for  placenta  praevia.  It  must  also 
be  distinguished  from  detachment  of  the  normally  situated  placenta. 
In  the  latter  there  is  no  elevation  of  the  retraction  ridge  nor  extra 
tension  in  the  round  ligaments.     There  is  no  sudden  change,  such 


582  -  COMPLEX  LABOR. 

as  is  found  in  most  cases  of  rupture  of  the  uterus.  Moreover, 
accidental  hemorrhage  generally  occurs  before  labor  or  in  the  early- 
first  stage.  Rupture  of  the  liver  or  spleen  may  simulate  that  of 
the  uterus  as  regards  shock  and  loss  of  blood,  but  no  abnormality 
is  necessarily  found  in  the  uterus. 

In  all  cases  it  is  essential  to  bear  in  mind  the  complications  that 
may  exist  with  uterine  rupture — /.  c,  prolapse  and  strangulation 
of  the  bowel,  rupture  of  the  bladder  or  rectum,  escape  of  the  liquor 
amnii  with  vernix  caseosa  and  meconium  into  the  peritoneal  cavity, 
and  septic  infection. 

Treatment. — Propln-lactic  measures  vary  according  to  the 
conditions  that  exist  in  any  giv^en  case.  The  most  careful  physical 
examination  is  necessary  to  determine  the  position  of  the  retrac- 
tion ridge  and  the  presence  of  an}-  of  the  causes  that  lead  to 
rupture.  If  it  be  feared  that  the  accident  may  occur,  the  patient 
should  be  anesthetized  to  diminish  uterine  activity  and  delivery 
should  be  promoted.  Sometimes  it  ma}'  be  that  a  cervix  requires 
to  be  dilated.  Forceps  delivery  or  embryulcia  may  be  indicated. 
Version  is  always  contraindicated,  since  it  increases  the  risk  of 
rupture.     In  some  cases  Caesarean  section  may  be  necessary. 

When  rupture  occurs,  various  procedures  may  be  adopted. 
When  it  is  incomplete,  the  fetus  being  in  the  uterus,  delivery 
should  be  accomplished  by  means  of  forceps  unless  the  cervix  be 
not  sufficiently  dilated,  or  there  be  some  obstruction  in  the  hard 
or  soft  parts  contraindicating  its  use.  Version  may  be  employed 
if  the  presentation  be  transverse  or  if  the  fetus  be  alive  and  not 
firmly  impacted  ;  but  if  it  be  dead  or  impacted,  embryulcia  or 
Ca.'sarean  section  is  necessan'.  If  the  cervix  be  only  partiall}' 
dilated,  artificial  dilatation  may  be  necessar}-,  though  sometimes  it 
may  be  deemed  best  to  perform  Caesarean  section. 

After  removal  of  the  fetus  by  the  natural  passage  the  placenta 
should  be  separated  manually,  and  at  the  same  time  the  extent  and 
position  of  the  rupture  studied.  A  hot  saline  douche  should  be 
given  and  an  antiseptic  gauze  tampon  introduced  into  the  uterus. 
In  cases  of  complete  rupture,  if  the  fetus  has  not  passed  into  the 
peritoneal  cavity,  it  should  be  extracted  by  the  vaginal  route,  if 
possible,  either  by  forceps  or  after  embryulcia.  Version  should 
never  be  employed,  on  account  of  the  risk  of  increasing  the  rupture. 
After  removal  of  the  fetus  and  placenta  the  rent  should  be  ex- 
amined. If  the  latter  be  of  small  size,  the  uterus  should  be  packed 
with  antiseptic  gauze.  If  it  be  extensive,  abdominal  section  should 
be  performed.  This  is  especially  indicated  if  the  fetus  has  been 
dead  for  some  time.  When  the  fetus  has  passed  partly  into  the 
peritoneal  cavity,  it  is  rarely  expedient  to  attempt  withdrawal  and 
delivery  through  the  vagina,  unless  the  patient's  condition  be  too 
serious  to  allow  abdominal  section  to  be  performed.  In  such 
cases  the  fetus  may  be  firmly  held  by  the  retracted  uterine  tis- 


RUPTURE    OF   THE    UTERUS.  583 

sue,  and  withdrawal   may  enlarge  the  opening  and  cause  fresh 
bleeding. 

When  the  fetus  is  entirely  within  the  peritoneal  cavit>%  abdomi- 
nal section  should  be  performed.  The  fetus  and  placenta  should 
be  removed  and  the  rupture  sutured,  unless  it  be  too  extensive 
and  irregular  or  there  is  a  strong  suspicion  that  infection  has  been 
introduced.  In  the  latter  cases  hysterectomy  is  most  expedient ; 
this  should  be  followed  by  gauze  drainage  of  the  peritoneal  cavity 
into  the  vagina  for  a  {q^n  days.  If  the  patient's  condition  will  not 
warrant  the  performance  of  the  more  extended  operation  of  hys- 
terectomy, the  rupture  should  be  partially  sutured  and  an  anti- 
septic gauze  tampon  placed  in  the  pelvis  and  passed  through  the 
rupture  into  the  uterus  and  vagina.  The  abdomen  should  be  well 
flushed  with  hot  normal  saline  solution  and  closed.  In  all  cases 
of  rupture  the  effects  of  shock  and  loss  of  blood  must  be  counter- 
acted by  the  ordinary  well-known  measures,  saline  injections  into 
the  bowel  or  subcutaneous  tissue  being  especially  valuable ;  these 
are  of  the  greatest  value  when  operative  measures  are  to  be  carried 
out.  In  performing  abdominal  section  every  moment  should  be 
considered  as  precious,  delay  increasing  the  patient's  risk. 

When  prolapse  of  the  intestine  follows  removal  of  the  fetus  by 
the  vaginal  route,  an  effort  should  be  made  to  replace  it  at  once. 
This  may  be  expedited  by  raising  the  level  of  the  patient's  hip. 
If  reposition  is  impossible,  abdominal  section  is  necessary.  When 
strangulation  exists,  the  latter  procedure  must  be  adopted  and  re- 
section of  the  gut  performed  if  the  bowel  be  much  injured.  If  the 
rectum  be  torn,  it  should  be  sutured.  When  the  bladder  is  rup- 
tured, abdominal  section  should  be  performed  as  soon  as  the  con- 
dition is  determined.  The  bladder  rent  should  be  sutured  and  the 
uterus  treated  on  the  lines  already  indicated.  The  bladder  should 
afterward  be  drained  several  days.  If  the  uterus  interferes  with 
satisfactory  closure  of  the  bladder,  the  former  should  be  sacrificed 
if  deemed  necessary. 

I/acerations  of  the  Cervix. — The  cervix  may  be  torn  in 
abortion  and  in  premature  and  full-time  labor,  most  frequently  in 
the  latter.  It  may  be  produced  by  the  passage  of  the  head  or 
body  of  the  fetus,  especially  if  the  labor  be  precipitate,  the  cervix 
be  rigid,  or  the  presentation  or  position  be  abnormal  ;  in  artificial 
dilatation  of  the  cervix ;  in  artificial  delivery  before  the  cervical 
canal  is  sufficiently  dilated ;  in  instrumental  or  normal  manipula- 
tions, and  in  cases  in  which  the  lip  of  the  cervix  is  incarcerated 
between  the  fetal  head  and  the  pelvic  wall.  In  the  great  majority 
of  cases  the  vaginal  portion  of  the  cervix  is  alone  affected  ;  occa- 
sionally more  of  its  substance  may  be  involved.  The  site  of  the 
laceration  is  variable.  Most  commonly  it  is  found  on  the  left  side 
(to  be  associated  with  the  most  frequent  position  of  the  head  in 


584  COMPLEX  LABOR. 

labor — viz.,  that  in  which  the  occiput  is  left  anterior).  Sometimes 
the  right  side  may  be  torn.  Sometimes  more  than  one  laceration 
is  produced  in  a  labor.  Rarely  a  circular  portion  of  the  cervix 
may  be  torn  off  Lacerations  vary  in  appearance ;  they  may  be 
simple  fissures  or  irregular  gaping  clefts.  Sometimes  the  cervical 
tear  extends  as  well  into  the  vaginal  wall ;  rarely  into  the  bladder. 
Bleeding  usually  follows  as  the  result  of  tearing,  after  the 
birth  of  the  child.  In  some  cases  it  may  be  noticed  at  an  earlier 
period — c.  g.,  where  artificial  dilatation  of  the  cervix  is  the  cause. 
The  hemorrhage  may  be  considerable  ;  rarely  it  may  be  alarming. 
It  must  always  be  early  diagnosed  from  the  bleeding  that  takes 
place  from  the  body  of  the  uterus.  Abdominal  examination  gen- 
erally suffices  to  differentiate  between  them.      When  the  blood 

flows  from  the  torn  cervix  there  is  no 
necessary  alteration  from  the  normal 
^^^^jjyc:;-   "  -.  retraction  and  contraction  of  the  uter- 

ine body.      Careful  vaginal   examina- 
/  tion  by  the  fingers    or  inspection  re- 

veals the  laceration  ;  only  in  this  way 
can  the  extent  of  the  tear  or  the  in- 
volvement of  neighboring  tissues  be 
estimated.  Examination  is,  however, 
rarely  necessary,  and  should  always 
be  made  with  the  strictest  asepsis. 

Cervical    laceration  is  occasionally 
serious  from  the  loss  of  blood  that  it 

Fig.  254.— Extornal  os  and  a  CaUSCS.  ItS  chief  significance  is,  how- 
portion  of  cervi.x  higher  up  which     g^g,   j^  relation  to  infection.     The  raw 

have  been  torn  off  during  dehverv  ^  1   •      r 

(Winckei).  "  "      suriace  produced  is  frequently  a  favor- 

able place  of  entrance  for  micro-organ- 
isms. Every  effort  should  be  made  to  check  hemorrhage,  success 
frequently  being  obtained  by  hot  douching.  If  this  be  insufficient, 
a  firm  vaginal  tampon  may  be  placed  against  the  cervix,  the  uterine 
body  being  pushed  well  down  through  the  abdominal  wall.  In 
serious  cases  tlie  cervix  may  be  exposed  with  a  speculum  and  the 
laceration  may  be  closed  with  chromic  catgut  sutures.  Immediate 
repair  should,  however,  never  be  carried  out  unless  the  facilities  are 
such  that  perfect  technic  may  be  observed  ;  otherwise  the  risk  of 
infection  is  great.  In  ordinary  practice  the  operation  is  rarely  neces- 
sary ;  reparative  measures  should  be  postponed  for  weeks  or  months. 
If  a  torn  cervix  be  not  stitched,  the  risk  of  infection  is  very  slight, 
providing  that  the  labor  be  conducted  properly.  Sometimes 
severe  hemorrhage  may  be  checked  by  the  application  of  hemo- 
static forceps  to  the  bleeding  points  for  ten  or  twelve  hours. 

I/acerations  of  the  Vagina. — The  hymen  is  stretched  and 
torn  in  almost  all  first  labors.  Very  rarely  after  retraction  no  evidence 
of  laceration  may  be  found  in  it.    The  vagina  may  be  torn  in  part 


RUPTURE    OF   THE    UTERUS.  585 

or  the  whole  of  its  extent.  The  conditions  favoring  lacerations 
are  brittleness  and  dryness,  often  found  in  old  primiparae ;  cicatricial 
changes  in  the  wall,  due  to  past  tears ;  operative  procedures  or 
inflammation ;  very  rapid  delivery  ;  dystocia  due  to  abnormalities 
on  the  part  of  the  fetus  or  hard  passages;  the  use  of  instruments, 
and  manual  interference.  The  lacerations  are  more  frequent  on 
the  posterior  than  on  the  anterior  wall.  When  the  upper  part  of 
the  vagina  is  affected,  the  tear  is  frequently  a  continuation  of  one 
in  the  cervix,  though  it  may  occur  independently.  Sometimes 
the  cervix  may  be  torn  completely  away  from  the  vagina.  The 
rent  may  be  transverse,  vertical,  oblique,  or  irregular.  It  varies 
greatly  in  depth,  involving  part  or  the  whole  thickness  of  the 
vaginal  wall,  and  may  extend  through  the  paravaginal  tissues, 
sometimes  as  far  as  the  bony  wall.  The  laceration  may  extend 
into  the  peritoneum,  rectum,  bladder,  urethra,  and  ureter.  Gen- 
erally the  relations  of  the  fetus  are  not  altered  by  vaginal  lacera- 
tion. Rarely,  when  the  peritoneum  is  opened,  the  fetus  or  part 
of  it  may  pass  through  the  opening.  When  the  rectum  is  torn,  a 
limb  may  pass  into  it.  When  the  lower  part  of  the  vagina  alone 
is  torn,  it  is  usually  associated  with  rupture  of  the  perineum,  in 
connection  with  which  it  will  be  considered. 

The  symptoms  associated  with  laceration  vary.  Sometimes 
there  is  a  certain  amount  of  shock,  but  it  is  never  so  marked  as 
in  cases  of  rupture  of  the  uterus.  Hemorrhage  is  usually  present 
and  may  be  very  profuse,  though  sometimes  it  may  not  be  marked 
until  the  child  is  delivered  ;  in  some  cases  it  may  be  very  slight. 
When  the  paravaginal  sinuses  are  torn,  the  bleeding  may  be  very 
profuse  and  alarming.  The  rent  may  sometimes  be  detected  soon 
after  it  is  produced,  especially  when  caused  by  the  hands  or  in- 
struments. When  it  occurs  spontaneously,  it  is  not  usually  found 
until  the  child  is  born,  unless  the  hemorrhage  has  led  to  an 
investigation.  Vaginal  lacerations  may  be  repaired  at  the  time 
of  their  occurrence  by  sutures  if  they  can  be  introduced  with 
perfect  technic.  If  surgical  cleanliness  is  impossible,  interference 
is  liable  to  infect  the  patient.  Fortunately,  the  hemorrhage  can 
be  checked  in  the  great  majority  of  cases  by  a  hot  douche  or  by 
vaginal  tamponade.  Occasionally,  when  the  bleeding  is  excessive, 
it  is  advisable  to  secure  the  bleeding  edges  of  the  rupture  with 
hemostatic  forceps,  which  may  be  left  in  position  for  twenty-four 
hours.  In  any  case,  if  the  edges  of  the  rupture  be  contused  or 
edematous,  it  is  best  not  to  introduce  sutures,  as  they  are  liable  to 
tear  out. 

If  the  peritoneal  cavity  be  opened,  allowing  the  intestine  to 
enter  the  vagina,  the  bowel  should  be  replaced  after  being  washed 
with  hot  normal  saline  solution,  and  an  antiseptic  tampon  placed 
in  the  rent  and  packed  in  the  vagina.  If  the  rupture  be  very 
large,  it  may  be  partly  closed  with  catgut  sutures. 


586  COMPLEX  LABOR. 

If  the  fetus  has  passed  into  the  abdominal  cavity,  the  case  is 
treated  on  the  Unes  indicated  in  considering  rupture  of  the  uterus 
followed  by  this  complication.  When  the  bladder  or  rectum  is 
opened,  closure  should  be  carried  out  at  once  if  proper  technic 
can  be  instituted ;  otherwise,  attention  should  be  given  to  the 
prevention  of  the  upward  extension  of  infection,  repair  work  being 
left  until  a  later  period. 

I/acerations  of  the  Parts  External  to  the  Vagina. — 
Frequently  the  vestibule  is  torn  mesially  or  laterally ;  the  tear 
may  extend  along  the  clitoris  or  urethra.  In  some  cases  it  may 
be  associated  with  considerable  contusion  or  with  laceration  of 
neighboring  parts — /.  e.,  labia  majora,  labia  minora,  or  vaginal 
wall.  The  labia  majora  or  minora  may  alone  be  torn,  the  lacera- 
tions varying  greatly  in  extent  and  shape.  Sometimes  multiple 
tears  are  produced.  Such  lacerations  are  best  treated  by  sutures, 
the  external  genitals  being  constantly  covered  with  moist  anti- 
septic dressings  during  the  early  days  of  the  puerperium. 

I/acerations  of  the  Perineum. — Though  this  expression 
has  long  been  in  use,  it  is  liable  to  be  misinterpreted.  The 
perineal  body  should  not  be  studied  as  a  separate  entit}'.  It  is 
merely  the  anterior  portion  of  the  sacral  segment  of  the  pelvic 
floor,  and  is  a  composite  structure,  composed  of  different  fascial 
and  muscular  structures.  Of  these,  the  most  important  are  the 
following :'  Triangular  ligament,  anterior  and  posterior  layers ; 
rectovaginal  visceral  layer,  anal  fascia,  and  deep  superficial  fascia. 

The  muscles  that  meet  in  the  perineum  are  the  transversus 
perinei,  transversus  perinei  profundus,  small  offshoots  of  the 
levatores  ani,  sphincter  vaginae,  and  sphincter  ani. 

The  significance  of  the  laceration  depends  upon  the  extent  and 
number  of  these  various  structures  dixided. 

In  the  majority  of  labors  the  fourchet  in  front  of  the  perineum 
is  torn.  Frequently  this  is  associated  with  shght  laceration  of  the 
anterior  margin  of  the  perineum  ;  in  other  cases  a  deeper  tear  is 
produced.  It  is  usually  mesial,  but  may  extend  on  one  or  both 
sides,  involving  the  vagina  or  inner  surface  of  the  vulva.  In 
more  marked  cases  part  or  the  whole  of  the  sphincter  ani  may  be 
involved.  The  rectovaginal  septum  may  be  torn  slightly  or  ex- 
tensively. Rarely  the  perineum  may  be  ruptured  between  the 
anus  and  the  anterior  margin.  Central  rupture  may  be  incom- 
plete, affecting  only  the  vaginal  or  the  skin  surface,  or  complete. 
It  may  occur  spontaneously  or  may  be  due  to  injury  with  instru- 
ments ;  the  child  may  or  may  not  be  delivered  through  the  lacera- 
tion. Frequently  the  various  tissues  are  lacerated  subcutaneously 
with  little  or  no  external  laceration. 

The  following  conditions  lead  to  rupture  :  Large  head  or  body 
of  the  child  ;  precipitate  labor ;  rigidity  of  the  tissues ;  excessive 
softness — i.  e.,  edema  ;  improper  use  of  instruments  ;  introduction 


RUPTURE    OF   THE    UTERUS.  587 

of  the  hand  without  previous  dilatation  ;  deHvery  of  malrotated 
occipitoposterior  or  face  cases  ;  narrow  subpubic  angle  ;  straight 
sacrum,  and  excessive  anteroposterior  measurement  of  perineum. 
Tearing  is  favored  by  flexion  of  the  thighs  on  the  abdomen.  The 
more  the  thighs  are  extended,  the  more  the  perineal  tissues  are 
relaxed.  All  tears  of  the  perineum  are  to  be  regarded  as  serious, 
not  only  because  of  the  increased  risk  of  infection  arising  from 
them,  but  chiefly  because  of  troubles  that  may  arise  afterward 
from  the  weakness  produced  in  various  elements  of  the  supporting 
framework  of  the  pelvic  floor ;  and,  in  complete  tears,  from  inter- 
ference with  the  sphincters  of  the  anus.  Hemorrhage  results  from 
perineal  tearing,  but  it  is  rarely  excessiv^e. 

Treatment. — The  prophylactic  measures  to  be  observed  in 
labor  for  the  prevention  of  rupture  of  the  perineum  have  already 
been  described  (p.  230).  Slight  tears  that  involve  the  skin  alone 
may  or  may  not  be  repaired ;  they  should  not  be  sutured  if  the 
procedure  cannot  be  carried  out  aseptically.  Deeper  tears  should 
always  be  stitched  at  the  end  of  the  delivery  if  the  operation  can 
be  properly  performed.  If  the  light  be  poor,  the  assistance  limited, 
and  the  facilities  scanty,  or  if  thorough  asepsis  cannot  be  assured, 
the  procedure  should  be  postponed  for  a  i^^  hours  (not  later  than 
twelve)  until  it  can  be  thoroughly  carried  out.  In  the  interval 
dressings  soaked  in  antiseptic  solutions  should  be  applied  to  the 
vulva.  It  has  been  successfully  done  several  hours  later  than  the 
period  mentioned,  but  the  chances  of  poor  union  are  great.  If  the 
operation  cannot  be  well  performed  within  twelve  hours  of  labor, 
it  should  be  postponed  for  seven  or  eight  weeks. 

In  repairing  a  laceration  the  patient  should  be  placed  in  the 
lithotomy  position,  the  genitalia  and  buttocks  being  cleansed  and 
protected  with  sterile  coverings.  If  the  tear  be  superficial  or  of 
medium  depth,  a  series  of  interrupted  stitches  should  be  introduced 
along  the  wound,  from  the  upper  to  the  lower  end.  Each  should 
enter  the  skin  \  cm.  external  to  the  tear  and  should  be  carried 
deeply  under  the  raw  surface,  emerging  at  a  point  in  the  skin 
opposite  the  place  of  entrance.  When  the  laceration  extends  along 
the  vagina  or  vulva,  it  also  should  be  closed.  Thoroughness  is 
necessary  in  performing  this  operation,  in  order  that  the  wound 
may  be  closed  in  its  entire  depth,  and  not  the  skin  edges  only. 
The  suture  material  may  be  linen,  silkworm-gut,  silk,  or  chromic 
gut.  Antiseptic  dressings  may  be  kept  on  the  vulva  several  days 
after  the  operation.  Catheterization  may  be  necessary  for  a  day  or 
two.  The  bowels  should  be  kept  regularly  open,  straining  at  stool 
being  forbidden. 

In  cases  of  laceration  involving  the  anus  the  edges  of  the  rent 
in  the  latter  are  fir.st  closed  by  a  fine  running  chromic-gut  suture, 
tied  on  the  bowel  side.  The  ends  of  the  torn  sphincter  muscles, 
which  are  usually  retracted,  should  be  lifted  up  with  forceps  and 


588  ,  COMPLEX  LABOR. 

stitched  together  with  catgut.  The  rest  of  the  wound  is  then 
closed  with  a  series  of  interrupted  silkworm-gut  or  linen  sutures, 
in  the  manner  described  in  speaking  of  medium  tears. 

After  this  operation  wet  antiseptic  dressings  are  constantly 
appHed  to  the  perineum  and  vulva  for  four  or  five  days.  The  vagina 
is  douched  daily  with  an  antiseptic  solution — normal  saline  solu- 
tion containing  formalin  (gtt.  xxiv-Oj).  The  patient  may  require 
to  be  catheterized  for  a  day  or  two.  The  bowels  need  not  be  dis- 
turbed for  four  days.  Then,  before  the  first  movement,  a  mixture 
of  olive  oil  (sij)  and  glycerin  (sj)  should  be  carefully  injected  into 
the  rectum  by  the  medical  attendant,  in  order  to  soften  the  feces. 
The  patient  is  cautioned  not  to  strain.  Non-absorbable  sutures 
may  be  removed  in  eight  or  nine  days.  The  patient  should  lie  in 
bed  until  the  sixteenth  day,  or  longer  if  healing  be  not  satisfactory. 


INVERSION  OF  THE  UTERUS. 

This  condition,  in  which  the  fundus  is  depressed  within  the 
cavity  of  the  uterus,  is  a  rare  complication  of  labor.  It  is  found 
in  various  degrees  : 

{ci)  As  a  cup-shaped  concavity  of  the  fundus. 

i^b)  The  depressed  fundus  may  lie  within  the  cervical  canal  or 
partly  in  the  vagina. 

(r)  The  body  of  the  uterus,  turned  inside  out,  may  lie  in  the 
vagina  or  partly  protruding  through  the  vulva. 

It  is  most  frequently  produced  during  the  third  stage  ;  in  some 
cases  within  a  few  hours  of  labor ;  rarely  at  a  later  period  in  the 
puerperium. 

Ktiology. — In  order  that  the  uterus  may  become  inverted  the 
normal  contraction  and  retraction  must  be  absent,  partially  or 
completely.  The  organ  may  be  found  momentarily  in  this  soft- 
ened condition  in  normal  cases  immediately  after  the  fetus  is  ex- 
pelled, but  in  the  great  majority  of  cases,  when  a  longer  period  of 
deficient  contraction  and  retraction  is  present,  some  factor  has 
been  in  operation  producing  the  inertia — e.  g.,  precipitate  labor, 
prolonged  labor,  hydramnios,  twins,  excessive  child-bearing,  etc. 
Inversion  is  impossible  if  normal  retraction  and  contraction  exist. 
When  partial  inertia  exists,  it  is  generally  believed  to  affect  that 
part  of  the  uterus  to  which  the  placenta  is  attached.  When  com- 
plete inertia  exists,  inversion  may  be  caused  in  various  ways. 
There  may  be  traction  on  the  cord,  while  the  placenta  is  attached, 
if  the  delivery  take  place  while  the  woman  is  standing,  or  if  the 
cord  be  naturally  or  accidentally  very  short  and  the  birth  take 
place  in  any  position.  Apart  from  spontaneous  production,  in- 
version may  be  caused  by  artificial  traction  on  the  cord  or  on  an 
adherent  placenta  when  there  is  inertia  of  the  uterus.  If  the  latter 
condition  be  not  present,  it  is  unlikely  that  inversion  can  be  pro- 


INVERSION   OF   THE    UTERUS. 


589 


duced.  It  is  stated  by  several  authorities  that  occasionally  spon- 
taneous inversion  may  be  caused  by  excessive  intra-abdominal 
pressure — c.  g.,  straining  or  coughing. 

External  manipulations  of  the  uterus  through  the  abdominal 
wall,  for  the  purpose  of  compressing  the  organ  or  expelling  the 
placenta,  may  cause  inversion.  In  cases  of  partial  inertia  of  the 
uterus,  usually  of  that  portion  to  which  the  placenta  has  been  at- 


FlG.  255. — Complete  inversion  with  prolapse  (Boivin  and  Duges) :  a,  Mens  veneris; 
b,  labium  majorus;  c,  labium  minorus;  d,  clitoris;  e,  urinary  meatus;/",  external  ante- 
rior border  of  vagina;  g,  external  border  of  os  uteri ;  h,  internal  surface  of  uterus,  now 
external. 


tached,  inversion  may  be  brought  about  spontaneously  through 
contractions  in  the  surrounding  active  uterine  musculature.  The 
placental  part  of  the  wall,  remaining  inert,  is  depressed  within  the 
uterine  cavity.  If  the  placenta  be  attached,  its  weight  tends  to 
drag  the  wall  still  farther  down.  The  intestines  also  sinking  into 
the  depression  help  to  promote  its  descent.  Traction  on  the  cord 
or  placenta  or  faulty  manipulations  of  the  fundus  may  initiate  or 
promote  inversion  in  these  cases. 


590  COMPLEX  LABOR. 

Pathology. — In  suddenly  produced  inversion  the  inverted  por- 
tion may  lie  in  the  vagina  or  partly  protrude  through  the  vulva.  It 
may  be  smooth,  if  covered  by  the  placenta  and  membranes,  or  raw, 
red,  soft,  and  bleeding  if  the  latter  are  absent.  In  some  cases  the 
placenta  may  be  only  partially  attached.  The  raw  surface  is  irregu- 
lar, clots  may  be  seen  in  the  opened  blood-sinuses,  and  sometimes 
the  openings  of  the  tubes  may  be  visible.  On  palpation  the  mass  is 
found  to  vary  in  consistence  :  it  may  be  soft  and  compressible,  or 
may  be  hard  when  the  musculature  is  contracted.  The  cervix  may 
be  felt  loose  around  the  inverting  mass  or  may  form  a  tight  con- 
striction ;  it  may  be  partly  inverted,  but  never  completely.  Some- 
times the  vagina  may  be  somewhat  inverted.  The  uterine  mass 
may  be  very  dark,  owing  to  excessive  congestion,  and  its  tissues 
may  become  very  edematous.  The  ovaries,  tubes,  and  even 
omentum  and  intestines  may  rest  in  the  depression  on  the  peri- 
toneal surface  of  the  uterus.  The  depression  tends  to  shrink  in 
course  of  time.  When  the  uterus  is  prolapsed  as  well  as  inverted, 
the  bladder  is  dragged  down.  When  complete  inversion  is  not 
produced,  the  depression  in  the  uterus  is  easily  felt  through  the 
abdominal  wall,  while  the  vaginal  fingers  feel  the  inserted  part  of 
the  uterine  body  through  the  cervix. 

Symptomatology. — When  the  inversion  is  slight,  there  may 
be  no  s)mptoms  whatever  ;  sometimes  there  m.a}^  be  more  or  less 
bleeding.  When  the  inverted  portion  reaches  the  cervix,  the 
patient  may  complain  of  distress  or  pains,  though  these  may  be 
absent.  In  cases  of  complete  inversion  the  patient  may  feel  as  if 
something  had  given  way  ;  there  may  be  severe  pain,  hemorrhage, 
and  collapse.  A  mass  is  felt  in  the  vagina  and  there  may  be 
marked  desire  to  urinate.  Occasionally  complete  inversion  may 
be  produced  without  an}-  special  signs  or  symptoms  whatever. 

Physical  Bxamination. — Bimanually  the  normal  convexity 
of  the  fundus  is  found  absent  and  a  depression  is  felt,  varying 
according  to  the  extent  of  the  inversion.  In  marked  cases  a 
mass  is  felt  at  the  vulva  or  in  the  vagina,  with  the  characters 
already  described  ;  it  is  somewhat  moulded  by  the  vaginal  wall. 
The  rim  of  the  cervix  can  usually  be  distinguished,  and  a  finger 
may  be  passed  up  around  the  inverting  portion  in  some  cases. 
This  is  impossible  when  the  cervix  forms  a  tight  constriction.  If 
the  inversion  has  not  passed  the  cervix,  a  finger  passed  into  the 
cavity  may  distinguish  the  condition. 

Inversion  of  the  uterus  must  be  distinguished  from  :  i.  Intra- 
uterine polypus.  2.  Polypus  extending  into  the  vagina.  3. 
Polypus  with  inversion.  4.  Prolapsus  uteri.  5.  Inversion  with 
prolapsus  uteri. 

The  inverted  mass  may  also  be  mistaken  for  the  head  of  a 
second  fetus,  for  a  placenta,  or  a  vulvovaginal  thrombus.  Serious 
results  may  follow  a  mistake  in  diagnosis. 


INVERSION   OF   THE    UTERUS.  59 1 

Course  and  Results. — In  the  majority  of  cases  the  inver- 
sion, whether  partial  or  complete,  is  rapidly  produced.  Occasion- 
ally the  change  is  gradually  brought  about,  a  marked  inversion 
being  produced  only  during  the  course  of  several  days.  In  all 
cases  there  may  be  hemorrhage,  and  this  may  sometimes  be  very 
serious.  In  complete  inversion  the  uterine  mass  may  become 
gangrenous,  infection  may  occur,  inflammation  and  ulceration  of 
the  surface  may  be  extensive  ;  secondarily,  peritonitis  may  follow. 
Death  may  be  due  to  shock,  loss  of  blood,  or  sepsis.  Rarely 
spontaneous  reposition  of  a  partial  inversion  may  be  noted. 
Sometimes  the  gangrenous  inverted  portion  may  separate.  Occa- 
sionally a  condition  of  chronic  inversion  may  develop. 

Treatment. — Inversion  of  the  uterus  should  almost  never 
occur  if  labor  be  conducted  properly.  The  causes  of  uterine 
inertia  should  be  prevented  as  much  as  possible ;  if  this  com- 
plication exists,  special  care  should  be  taken  to  induce  retrac- 
tion and  contraction.  The  fundus  should  not  be  depressed  by 
manipulations  through  the  abdomen.  The  cord  and  placenta 
should  not  be  pulled  until  separation  from  the  uterine  wall  is 
insured.  Frequent  examinations  of  the  uterus  through  the  ab- 
dominal wall  should  be  made. 

When  partial  inversion  exists,  reposition  is  easily  brought  about 
by  bimanual  manipulations.  If  the  placenta  be  attached,  it  should 
be  removed  by  the  fingers.  When  complete  inversion  exists,  it 
should  be  replaced  as  soon  as  possible ;  in  order  to  do  this  the 
patient  should  be  anesthetized,  placed  in  the  lithotomy  position, 
and  a  thorough  aseptic  technic  observed.  The  rectum  and  blad- 
der should  be  empty,  and  the  placenta  should  be  removed,  if 
attached,  before  reposition  is  attempted.  In  carrying  out  taxis 
the  following  methods  may  be  adopted  :  One  hand  is  placed  on 
the  abdomen,  steadying  the  cervix,  while  the  other  grasps  the 
fundus,  pushing  it  up  and  undoing  the  inversion,  following  the 
axis  of  the  pelvis.  If  this  method  fail,  an  effort  may  be  made  to 
dimple  in  one  part  of  the  wall  near  the  cervix,  making  the  rest 
follow,  while  the  other  hand  endeavors  to  enlarge  the  cervical 
ring  through  the  abdominal  wall.  Sometimes  the  fundus  may  be 
dimpled,  reduction  of  the  inversion  following.  When  reposition 
fails  by  these  manipulations,  the  patient  should  be  kept  in  bed  on 
low  diet  for  several  hours,  hot  antiseptic  douches  or  fomentations 
being  applied  to  the  inverted  uterus.  The  bowels  and  bladder 
should  be  thoroughly  emptied  and  manipulations  should  again  be 
attempted.  If  these  fail  on  account  of  the  tightness  of  the  con- 
stricting cervix,  the  latter  should  be  divided  in  the  middle  line, 
anteriorly  or  posteriorly,  or  in  both  places,  as  recommended  by 
Matthews  Duncan,  in  order  to  facilitate  reduction.  In  all  manipu- 
lations the  uterine  wall  must  be  handled  gently,  lest  it  be  torn  or 
injured.  After  reposition  it  is  always  advisable  to  tampon  the  uterine 


592  COMPLEX  LABOR. 

cavity  for  twenty-four  or  forty-eight  hours.  The  measures  to  be  fol- 
lowed in  chronic  inversion  or  in  inversion  complicated  by  sepsis  need 
not  be  described  here,  as  they  belong  to  the  domain  of  gynecology. 

Hematoma. — This  condition  has  already  been  referred  to  as 
a  cause  of  delay  in  labor ;  it  may  also  develop  at  the  end  of  labor. 
Most  frequently  the  labia  majora  are  affected,  but  blood  may  also 
be  effused  into  the  labia  minora,  vaginal  wall,  cervix,  parametrium, 
retroperitoneal  tissues  of  the  anterior  and  posterior  pelvic  and 
abdominal  walls,  and  elsewhere.  In  most  cases  the  blood  is 
extravasated  before  the  end  of  labor  and  accumulates  afterward. 
According  to  the  situation  of  the  extravasation,  variations  are 
found  in  the  size  and  extent  of  the  hematoma.  When  the  blood 
is  poured  out  near  the  peritoneum,  large  swellings  may  result. 

The  reason  for  the  rupture  of  vessels  is  not  known  in  all  cases. 
Throughout  the  pelvis  there  is  increased  congestion  of  the  ves- 
sels ;  in  some  parts  they  are  much  increased  in  size.  Sometimes 
the  veins  become  markedly  varicose.  It  is  easy  to  understand 
why  the  traumatism  of  labor  may  lead  to  rupture.  The  injured 
vessel  is  usually  a  vein. 

The  hematoma  develops  with  varying  rapidity  in  different 
cases.  Sometimes  it  is  very  gradual  in  formation.  The  disten- 
tion of  the  tissues  with  blood  often  causes  pain,  though  in  some 
cases  this  symptom  may  be  absent.  When  the  extravasation  is 
marked,  the  usual  signs  and  symptoms  of  loss  of  blood  may  be 
present.  On  physical  examination  the  swelling  is  found  localized 
or  diffused,  fluctuating  or  tense,  and  dark  in  color  if  it  be  visible. 
The  mass  may  interfere  with  the  passage  of  the  fetus  or  placenta, 
or  afterward  with  the  escape  of  the  lochia.  It  may  be  mistaken 
for  a  mass  of  varicose  veins,  hernia,  prolapse,  or  inversion  of 
the  uterus  or  vagina.  It  has  been  diagnosed  as  a  fetal  head  or  as 
placenta  prasvia  in  labor. 

A  hematoma  may  burst  externally  or  into  the  peritoneum  with 
serious  or  fatal  results.  It  may  gradually  become  absorbed.  In- 
fection may  take  place  and  suppuration  follow. 

As  regards  treatment,  if  the  swelling  be  large  enough  to  ob- 
struct labor,  it  should  be  incised  and  the  clots  expelled.  After  the 
fetus  and  placenta  are  delivered,  the  bleeding  may  be  checked  by 
sutures  or  by  a  tampon  and  firm  pressure.  When  the  hematoma 
is  noticed  only  after  deliv^ery,  pressure  may  prevent  its  increase. 
Absorption  is  promoted  by  rest.  If  the  mass  be  visible,  care  must 
be  taken  to  prevent  infection.  If  rupture  threatens,  the  mass 
should  be  opened  and  packed  with  antiseptic  gauze.  If  internal 
rupture  occurs,  abdominal  section  is  necessary. 

Rupture  of  the  Pelvic  Joints. — The  symphysis  pubis  may 
be  ruptured  as  the   result   of  forced   delivery  after  turning  or  by 


INVERSION  OF   THE    UTERUS.  593 

means  of  forceps.  It  is  most  frequent  in  instrumental  cases ;  it 
rarely  occurs  spontaneously.  Rupture  is  favored  by  excessive 
softening  of  the  joint  ligaments  or  by  disease. 

Sometimes  the  patient  feels  the  joint  tear  and  may  complain  of 
pain.  In  some  cases  the  accident  may  be  discovered  only  after 
labor,  when  the  patient  attempts  to  walk.  Sometimes  the  peri- 
toneum, bladder,  or  vagina  maybe  torn.  Suppuration  in  the  joint 
may  sometimes  follow  this  accident.  If  the  condition  be  neglected, 
permanent  weakness  may  be  established,  especially  interfering 
with  locomotion. 

Treatment. — Laceration  of  the  bladder  or  vagina  should  be 
immediately  repaired  with  sutures.  The  hips  should  be  bandaged 
firmly,  as  after  a  symphysiotomy,  or  a  hammock  bed  should  be 
used  and  the  patient  kept  at  rest  for  five  or  six  weeks. 

Rupture  of  the  sacro-iliac  joints  may  be  caused  in  the 
same  manner  as  tearing  of  the  symphysis  pubis.  Pain  may  be  felt 
in  the  region  of  the  joints  at  the  time  of  the  occurrence  of  rupture, 
but  the  chief  discomfort  is  felt  when  the  woman  sits  up  or  at- 
tempts to  walk.  There  are  a  sense  of  distress  and  insecurity  and 
weakness  in  the  lower  limbs.  The  trouble  is  intensified  if  inflam- 
mation of  the  joint  follows  rupture.  When  the  lesion  occurs,  the 
patient  should  be  kept  at  rest  in  bed  for  two  months  at  least,  the 
hips  being  inclosed  in  firm  strapping,  and  the  joints  kept  from 
movement  by  double  long  splints  or  some  other  suitable  ortho- 
pedic apparatus.  A  hammock  bed  may  also  be  used  in  these 
cases. 

Sometimes  the  sacrococcygeal  or  one  of  the  intercoccygeal 
joints  may  be  stretched  or  torn  in  labor,  leading  to  distress  or 
pain. 

Fractures  of  the  Pelvic  Bones. — Rarely  the  rami  of  the 
pubes  and  ischium  may  be  injured  by  the  injudicious  use  of 
forceps.  Ankylosed  coccygeal  bones  or  the  junction  of  the  coccyx 
and  sacrum  may  sometimes  be  spontaneously  broken  by  strong 
expulsive  efforts  when  the  head  is  low  in  the  pelvis  ;  sometimes 
the  injury  is  caused  by  forceps  delivery.  Ankylosis  of  these  bones 
is  chiefly  found  in  old  primiparae.  The  rupture  may  be  transverse, 
oblique,  or  irregular.  Considerable  distress  or  pain  may  afterward 
be  felt  in  the  region  of  the  coccyx.  The  severed  portions  may 
heal  in  such  a  manner  as  to  cause  obstruction  in  a  succeeding 
pregnancy. 

Diastasis  of  the  Recti  Abdominis  Muscles. — Reference 
has  already  been  made  to  the  separation  of  the  recti  muscles  and 
the  stretching  of  the  linea  alba  in  pregnancy.  The  condition  is 
found  to  a  varying  extent  in  almost  all  women  who  have  borne 


594  COMPLEX  LABOR. 

children.  It  is  least  marked,  as  a  rule,  in  primiparae,  and  most 
developed  in  those  who  have  had  a  number  of  children.  Indeed, 
the  examination  of  the  abdomen  of  primigravidae  in  a  large  number 
of  maternity  cases  has  convinced  me  that  in  the  great  majority  of 
women  there  is  some  degree  of  separation  of  the  recti  in  the  region 
of  the  navel  as  a  result  of  the  distention  of  pregnancy.  In  many 
instances,  however,  after  labor  owing  to  retractibility  of  the  ab- 
dominal wall,  all  evidence  of  stretching  may  disappear,  though 
in  a  considerable  proportion  of  cases  permanent  widening  remains, 
which  is  likely  to  become  increased  in  succeeding  pregnancies. 

All  conditions  increasing  intra-abdominal  pressure  in  pregnancy 
tend  to  favor  the  development  of  the  diastasis.  Thus,  women  who 
work  hard  in  the  second  half  of  pregnancy,  especially  those  who 
lift  or  carry  heavy  weights,  are  more  apt  to  become  affected. 
Sometimes  a  sudden  strain  or  fall  is  the  starting-point  of  the  con- 
dition. Among  all  classes  the  wearing  of  corsets  in  pregnancy  is 
not  infrequently  an  important  associated  cause.  It  is  very  easy  to 
understand  how  this  acts  detrimentally.  The  intra-abdominal 
space  being  artificially  constricted  above,  and  being  gradually  en- 
croached on  by  the  growing  uterus  from  below,  the  various  viscera 
are  more  and  more  compressed  into  the  intermediate  area,  where 
the  weakest  and  least  resistant  portion  of  the  abdominal  wall  is 
the  region  of  the  umbilicus.  Excessive  development  of  the  uterus, 
— /.  f'.,  hydramnios, — the  presence  of  an  abdominal  tumor,  etc.,  are 
to  be  placed  among  the  causes.  In  all  women  flatulence  and  con- 
stipation, and  abundant  adipose  tissue  in  the  mesentery  and 
omentum,  must  be  regarded  as  favoring  causes.  So  also  is  any 
condition  that  induces  excessive  coughing  in  pregnancy.  General 
weakness  or  emaciation  by  lowering  the  tone  of  the  tissues  of  the 
abdominal  wall  also  predisposes.  Straining  during  the  second 
stage  of  labor  may  lead  to  increased  stretching  of  the  linea  alba, 
especially  if  the  stage  be  prolonged  or  the  expulsive  efforts  be 
verv^  strong.  Immediately  after  labor  the  extent  of  stretching  can 
be  easily  estimated  by  careful  examination  of  the  abdominal  wall, 
the  muscles  being  brought  into  action  by  the  patient.  During  the 
puerperium  some  degree  of  retraction  takes  place  in  the  stretched 
tissues,  and  in  cases  in  which  the  recti  have  been  but  slightly 
separated  the  parts  may  return  almost  to  the  nulliparous  condition. 
In  many  instances,  however,  permanent  widening  remains,  which 
is  likely  to  become  increased  during  succeeding  pregnancies.  The 
condition  may  be  aggravated  after  labor  if  women  are  careless  in 
regard  to  those  influences  that  tend  to  increase  intra-abdominal 
pressure.  Thus,  constriction  of  the  waist  with  corsets  or  skirt, 
bands  may  cause  abdominal  pressure  on  the  linea  alba,  especially 
below  the  umbilicus.  If  a  woman  goes  to  work  too  soon,  especially 
if  she  lifts  or  strains  or  stands  long  on  her  feet,  the  linea  alba  is 
affected  unfavorably. 


HEART  DISEASE    COMPLICATING   LABOR.  595 

It  is  important  that  this  condition  be  recognized  in  every  in- 
stance, in  order  that  women  may  be  advised  concerning  it.  There 
is  no  doubt  that  it  is  a  frequent  cause  of  ill  health  in  women,  be- 
cause of  the  influence  it  exerts  in  the  production  of  enteroptosis. 
In  marked  conditions  it  may  lead  to  much  discomfort  in  pregnancy 
and  to  trouble  in  labor  (p.  427). 

Whenever  the  condition  exists  in  pregnancy  the  patient  should 
be  prevented  from  doing  heavy  work  and  from  standing  or  walk- 
ing too  much.  Corsets  should  be  removed,  the  skirts  should  be 
suspended  from  the  shoulders,  and  a  broad  silk-elastic  abdominal 
binder  should  be  worn.  After  labor  similar  rules  should  be  fol- 
lowed. During  labor  a  binder  may  be  necessary.  In  marked 
cases  it  may  often  be  advisable,  when  the  patient  is  not  pregnant, 
to  bring  the  separated  recti  together  by  a  surgical  operation. 
This  has  been  described  by  the  author  in  the  Journal  of  the 
American  Medical  Association,  Dec.  22,  1900. 

Rupture  of  an  Air-passage. — Rupture  of  some  part  of  the 
air-passages  is  a  rare  occurrence  in  labor ;  it  may  result  from 
excessive  straining.  The  air  escaping  from  the  passage  may 
cause  emphysema  in  the  subcutaneous  tissue  of  the  neck  and 
face  when  the  upper  tubes  are  injured,  or  in  the  lungs  when  the 
terminal  passages  are  ruptured.  As  soon  as  the  condition  is 
noticed  labor  should  be  artificially  ended,  the  patient  being  cau- 
tioned not  to  make  any  expulsive  efforts. 


HEART   DISEASE    COMPLICATING  LABOR. 

The  subject  of  cardiac  disease  in  relation  to  pregnancy  has 
already  been  considered  (p.  291).  The  conduct  of  labor  in  such 
cases  is  always  a  serious  responsibility. 

In  the  first  stage  of  labor  trouble  may  start  or  symptoms 
already  present  may  become  aggravated.  There  may  be  palpita- 
tion or  attacks  of  dyspnea.  The  exacerbation  is  due  to  the  in- 
creased strain  on  the  heart,  and  to  the  pulmonary  congestion 
during  the  periods  of  uterine  contraction  when  the  circulation  of 
blood  through  the  uterus  is  interfered  with.  If  straining  efforts 
are  made  by  the  patient,  the  symptoms  are  more  marked.  At  the 
termination  of  the  first  stage  after  rupture  of  the  membranes 
slight  relief  is  experienced  in  some  cases  as  a  result  of  some 
diminution  in  the  size  of  the  uterine  mass,  owing  to  the  escape 
of  liquor  amnii. 

During  the  progress  of  the  second  stage  the  condition  of  the 
patient  tends  to  become  worse.  This  is  probably  chiefly  due  to 
the  straining  efforts  made  to  bring  into  action  the  accessory 
powers.  Moreover,  the  uterine  contractions  are  longer  and  more 
powerful,  and  there  is  a  resulting  greater  strain  on  the  heart  from 


596  COMPLEX  LABOR. 

the  interference  with  the  uterine  circulation.  The  pulse  may  be- 
come more  rapid,  irregular,  or  intermittent,  the  breathing  may  be 
rapid  and  oppressed,  the  patient  being  restless  and  having  a  feeling 
of  great  anxiety. 

As  the  child  escapes  there  may  be  a  feeling  of  relief  on  the 
part  of  the  patient  from  the  great  diminution  in  abdominal  dis- 
tention, but  this  may  be  counterbalanced  by  another  factor — viz., 
the  interference  with  the  circulation  caused  by  the  retraction  of 
the  uterus  that  occurs  after  the  birth  of  the  child.  Though  we 
do  not  know  exactly  to  what  extent  the  circulation  through  the 
retracted  organ  is  arrested,  there  can  be  no  doubt  that  it  must  be 
greatly  slowed,  less  blood  circulating  through  it,  while  more  is 
thrown  into  the  non-uterine  vascular  system.  As  a  result  of  this 
there  is  an  increased  amount  poured  into  the  right  side  of  the 
heart  as  well  as  a  rise  in  arterial  pressure.  These  changes  in- 
crease the  patient's  risk,  and  often  the  symptoms  become  much 
worse  at  this  time.  Yet  it  is  very  rare  that  the  patient  dies  imme- 
diately after  the  child  is  born.  The  most  dangerous  period  is  yet 
to  follow. 

It  is  at  the  end  of  the  third  stage  that  there  is  the  greatest 
danger,  especially  in  mitral  stenosis  cases.  The  placenta  may  be 
born  all  right,  but  immediately  or  soon  afterward  the  patient  may 
die.  The  explanation  of  this  is  evident  if  the  condition  of  the 
pelvis  at  this  time  be  studied.  In  my  researches  into  the  anat- 
omy of  the  normal  pelvis  during  the  puerperium  I  found  that 
normally  after  the  delivery  of  the  placenta  the  retracted  and 
firmly  contracted  uterus  forms  a  large  mass,  which  fills  the  upper 
part  of  the  pelvis  like  a  ball-plug,  compressing  all  the  extra- 
uterine tissues  against  the  bony  wall.  As  a  result  of  this  the 
circulation  in  the  great  mass  of  the  uterus  is  practically  checked, 
the  organ  being  quite  anemic  ;  also,  owing  to  the  pressure  of  the 
uterus,  the  circulation  in  the  extra-uterine  pelvic  tissues  is  greatly 
interfered  with.  The  only  congested  parts  are  the  small  lower 
uterine  segment,  the  cervix,  the  vaginal  wall,  and  neighboring 
parts  of  the  pelvic  floor.  It  is  this  very  great  alteration  in  the 
circulation  that  throws  the  extra  burden  on  the  already  over- 
burdened heart.  The  whole  vascular  area  of  the  body  has  been 
greatly  diminished,  and  the  extra  strain  on  the  right  side  of  the 
heart  may  be  too  much  for  it ;  overdistention  of  its  already  weak 
and  thinned  walls  results,  and  paralysis  of  the  heart  may  follow. 
This  condition  in  mitral  disease  was  first  pointed  out  by  Spiegel- 
berg.  It  has  been  described  by  Berry  Hart,  and  I  have  also  noticed 
it  in  a  case  of  my  own  where  death  occurred.  Fritsch,  Barbour, 
and  others  deny  that  death  is  caused  in  this  way.  They  think 
that  extra  strain  is  not  throv/n  on  the  right  side  of  the  heart,  but 
believe  that  the  blood  thrown  out  of  the  uterine  circulation  is 
accommodated  in  the  extra-uterine  vessels  of  the  pelvis  and  ab- 


HEART  DISEASE    COMPLICATING   LABOR.  597 

domen,  owing  to  the  change  in  intra-abdominal  pressure  condi- 
tions consequent  upon  the  emptying  of  the  uterus.  They  say 
that  the  condition  brought  about  is  one  of  syncope,  and  that  the 
cardiac  failure  results  because  an  insufficient  amount  of  blood 
reaches  the  heart,  which  consequently  begins  to  beat  irregularly ; 
this  along  with  the  nutritive  defects  leading  to  a  fatal  ending. 

It  is  important  clearly  to  understand  the  difference  between 
these  two  views,  chiefly  because  the  methods  of  treatment  based 
upon  them  differ  so  markedly.  There  is  no  proof  of  Fritsch's 
theory.  Pathologic  evidence  is  against  it.  In  postmortem 
cases  there  are  usually  found  distention  of  the  right  side  of  the 
heart,  or  marked  distention  especially  of  one  or  both  auricles,  and 
pulmonary  congestion.  During  life  the  face  does  not  show  signs 
of  syncope,  but  is  flushed  or  deeply  cyanosed  during  the  period 
of  danger.  Fritsch's  theory  cannot  explain  the  death  that  follows 
emptying  of  the  uterus  in  early  pregnancy.  It  is  indeed  very 
interesting  to  note  that  the  strain  thrown  on  the  heart  by  an 
abortion  may  prove  too  much  for  it.  Moreover,  were  the  theory 
correct,  syncope  might  be  expected  often  to  follow  normal  labor, 
whereas  it  is  very  rare,  save  where  much  blood  has  been  lost. 
That  some  of  the  uterine  and  pelvic  blood  is  accumulated  in 
abdominal  parietal  and  visceral  vessels  after  the  uterus  is  empty 
and  contracted  is  undoubtedly  true ;  that  this  does  not  go  on  to 
the  extent  described  by  Fritsch  is  equally  true.  The  congestion 
of  these  vessels  that  does  occur  is  really  a  condition  of  safety  for 
the  patient,  for  the  strain  on  the  heart  will  be  for  a  time  dimin- 
ished in  proportion  to  the  amount  of  blood  accumulated  in  them. 
Very  soon,  however,  the  vasomotor  mechanism  will  tend  to 
diminish  this  accumulation,  thereby  correspondingly  increasing 
the  burden  on  the  heart.  These  various  factors  must  differ  con- 
siderably in  different  women,  and  it  is  not,  therefore,  difficult  to 
understand  why  there  should  be  such  variations  in  the  clinical 
phenomena  witnessed  in  a  series  of  cases  in  which  the  same 
cardiac  lesion  exists. 

When  labor  sets  in,  what  is  to  be  done  ?  The  patient  should 
be  carefully  watched  from  the  first.  If  she  has  been  previously  in 
good  condition,  she  may  be  allowed  to  go  through  the  first  stage 
without  interference,  an  occasional  dose  of  a  stimulant  being  given 
if  necessary.  If  she  be  very  restless  or  makes  straining  efforts,  she 
should  be  quieted.  If  it  is  impossible  to  manage  this,  and  if  signs 
of  heart  failure  appear,  the  patient  should  be  chloroformed  and  the 
cervix  dilated  with  Barnes's  bags  or  manually. 

We  are  now  at  the  second  stage.  In  some  instances  she  may 
pass  through  this  stage  without  trouble.  In  bad  cases,  however, 
especially  in  mitral  disease,  she  should  not  be  allowed  to  pass 
through  it  in  her  own  strength.  She  should  be  chloroformed  by 
an  assistant,  who  gives  his  whole  attention   to  his  duty,  while  the 


598  ""  COMPLEX  LABOR. 

child  is  extracted  with  forceps.  Occasional  inhalations  of  ether  may 
be  required.  I  wish,  however,  especially  to  recommend  the  use  of 
nitrite  of  amyl.  This  drug  was  first  tried  with  success  in  heart  dis- 
ease compHcating  labor  by  Fraser  Wright,  who  gave  it  after  the 
third  stage  was  completed,  when  his  patient  was  in  danger  of  dying 
of  pulmonary  and  cardiac  congestion.  Its  action  is  to  lessen  the 
strain  on  the  heart  through  the  dilatation  that  it  causes  in  the 
small  peripheral  vessels  throughout  the  body,  from  paralysis  either 
of  the  muscular  fibers  of  the  arterioles  or  of  the  vasomotor  g-anelia 
in  them.  .  Soon  after  its  administration  (from  twenty  to  thirty  sec- 
onds) its  effects  are  seen.  The  drug  is  best  given  by  the  chloro- 
formist  in  capsules  containing  4  or  5  minims,  which  are  broken 
and  held  to  the  patient's  nose.  It  is  also  useful  in  opposing  the 
tendency  to  chloroform  syncope  ;  a  threatening  of  this  condition 
may  be  kept  off  by  a  careful  anesthetist.  As  the  child  is  delivered 
the  nitrite  of  amyl  is  of  great  \-alue  in  neutralizing  the  increasing 
strain  on  the  heart  due  to  the  additional  blood  thrown  out  of  the 
uterine  circulation  as  a  result  of  the  uterine  retraction  that  follows 
deliveiy. 

Hypodermic  injections  of  nitroghxerin  may  be  used  instead  of 
amyl  nitrite. 

The  third  stage  now  follows — that  most  to  be  feared.  Opinions 
differ  regarding  the  treatment  to  be  employed  here.  According  to 
the  view  of  those  who  hold  that  the  danger  is  due  to  the  accumula- 
tion of  blood  in  the  abdom.inal  vessels  and  the  consequent  dimin- 
ished supply  to  the  heart,  the  loss  of  blood  even  in  drops  is  very 
dangerous.  According  to  the  view  that  appears  to  me  to  be 
correct,  and  which  I  ha\-e  advocated,  the  indication  is  not  to  con- 
serve, but  to  allow  the  free  escape  of,  a  certain  amount  of  blood 
from  the  body,  in  order  to  prevent  overdistention  of  the  lungs  and 
of  the  right  side  of  the  heart.  How  can  this  best  be  brought 
about?  The  patient  is  still  kept  under  chloroform  ;  ether  is  given 
hypodermically  from  time  to  time,  and  the  nitrite  tends  to  counteract 
the  contractilit}'  of  the  uterus,  and  so  to  delay  the  separation  and 
expulsion  of  the  placenta.  This  event  must  not  be  allowed  to 
take  place  naturally,  because  it  is  apt  to  cause  too  sudden  a  change 
in  the  vascular  pressure  and  to  prevent  the  loss  of  blood,  which  it 
is  our  chief  aim  to  bring  about.  Neither  should  the  Dublin  or 
Crede  method  of  expelling  the  placenta  be  used,  for  the  same 
reason.  The  most  satisfactory  procedure  is  to  pass  one  hand  into 
the  uterus,  separating  the  placenta  gradually,  the  other  hand  being 
placed  on  the  abdomen,  against  the  uterus.  As  the  sinuses  are 
torn  through  blood  escapes,  the  amount  lost  being  carefully 
watched.  In  carrying  out  this  operation  the  greatest  skill,  cool- 
ness, and  judgment  are  required.  As  the  uterus  retracts  and  con- 
tracts following  the  removal  of  the  placenta,  the  heart  should  be 
carefully  watched  and  another  dose  of  nitrite  of  amyl  given  if  nee- 


HEART  DISEASE    COMPLICATING   LABOR.  599 

essary.  If,  owing  to  the  amount  of  chloroform  and  amyl  nitrite 
administered,  marked  contraction  does  not  occur  in  the  uterus,  no 
alarm  should  be  felt.  This  condition  is  better  than  sudden  con- 
traction, because  the  changes  in  the  circulation  are  more  gradually 
brought  about.  The  organ  can  easily  be  compressed  between  the 
hands,  and  if  necessary,  the  hot  douche  can  be  used,  but  the  latter 
agency  should  not  be  employed  save  where  there  is  danger  of  the 
loss  of  too  much  blood.  Neither  should  ergot  be  used  in  these 
cases  except  in  the  last-mentioned  condition,  because  it  opposes 
the  escape  of  the  blood  from  the  uterus,  which  we  desire  to  a 
certain  extent  to  encourage.  Hitherto  it  has  been  recommended 
by  many  to  bleed  the  patient  from  the  neck  or  arm.  This,  it 
appears  to  me,  is  altogether  unnecessary,  when  we  have  at  our 
disposal  the  easy  method  of  bleeding  from  the  uterus  that  I  have 
just  described. 

The  treatment  of  heart  cases  during  the  puerperium  is  of  the 
greatest  importance.  Rest  in  bed  for  some  weeks  is  advisable. 
For  a  time  after  delivery  stimulants  of  ether  and  brandy  may  be 
required.  Strophanthus  or  digitalis  is  to  be  given  cautiously. 
The  most  easily  digested  nourishing  food  is  to  be  taken.  There 
should  be  no  straining  at  stool  or  in  passing  water.  The  bowels 
should  be  regulated  so  as  to  move  easily,  and  for  some  days  the 
urine  should  be  drawn  off.  The  retrogressive  changes  that  take 
place  in  the  heart  during  the  puerperium  introduce  a  new  element 
of  danger,  and,  therefore,  the  greatest  watchfulness  must  be  ex- 
ercised. Complete  quiet  and  good  nursing  are  imperative.  The 
patient  should  not  lose  sleep  nor  be  disturbed  in  any  way.  As 
soon  as  the  stomach  is  able  to  bear  iron  it  should  be  given. 

Diseases  of  the  Respiratory  Tract. — These  have  already 
been  considered  in  connection  with  pregnancy.  Labor  may  be 
very  serious  in  some  of  these  conditions — r.^.,  pneumonia.  Its 
conduct  is  practically  the  same  as  that  recommended  for  serious 
heart  lesions. 

Pulmonary  Embolism. — Embolism  of  the  pulmonary  ar- 
teries rarely  occurs  during  labor.  In  the  puerperium  it  may  also 
occur.  Von  Fiesenhausen  reports  that  only  3  cases  occurred 
during  twenty-five  years  among  50,000  labors  in  the  St.  Peters- 
burg Maternity.  In  each  of  these  the  symptoms  appeared  when 
the  patient  first  got  out  of  bed — in  one  on  the  fourth,  in  another 
on  the  sixth,  and  in  the  third  on  the  seventh  day.  Death  took 
place  in  2  cases  within  twenty-five  minutes,  and  in  the  third  in 
ten  minutes. 

It  is  stated  to  arise  from  clotting  in  the  right  side  of  the  heart, 
and  also  to  be  caused  by  clots  carried  from  the  uterine  veins,  es- 
pecially in  the  third  stage.  The  symptoms  are  dyspnea,  flutter- 
ing heart,  weak,  rapid  pulse,  cold  skin,  and  pale  face.     Death  may 


600  COMPLEX  LABOR. 

rapidly  occur.  There  may  be  an  improvement  for  a  short  period, 
followed  by  a  return  of  dyspnea,  cyanosis,  and  death.  Occasion- 
ally the  patient  may  recover,  infarct  formation  occurring  in  the 
lung,  usually  associated  with  hemoptysis. 

Treatment. — Diffusible  stimulants  are  valuable  and  oxygen 
may  be  administered. 

Air  i^mbolisiii. — Very  rarely  air  embolism  causes  death  or 
endangers  life.  The  air  is  believed  to  enter  the  uterine  sinuses  as 
a  result  of  improper  douching  when  the  placenta  is  partly  or  wholly 
separated,  in  carrying  out  intra-uterine  manipulations  that  affect 
the  placenta — c.  g.,  in  placenta  praevia.  The  symptoms  produced 
are  feeble  pulse,  cold  limbs,  dyspnea,  jerky  breathing,  and  cyanosis. 
On  postmortem  examination  little  blood  may  be  found  in  the  left 
heart,  frothy  blood  being  in  the  uterine  veins,  vena  cava,  right 
heart,  and  pulmonary  artery,  the  lungs  being  anemic  and  contain- 
ing frothy  serum. 

General  Bmbolism. — Rarely  in  labor  is  a  clot  formed  in  the 
left  heart  and  carried  to  one  or  more  arteries  in  the  shape  of 
emboli.  In  such  a  case  old  endocarditis  is  likely  to  be  present. 
The  symptoms  vaiy  according  to  the  artery  affected. 

Collapse. — Collapse  and  fainting  may  be  caused  in  labor  when 
serious  lesions  exist — c.  g.,  cardiac,  renal,  and  pulmonary  disease ; 
in  marked  loss  of  blood  from  any  cause — c.  g.,  rupture  of  the 
uterus  or  other  viscera,  separation  of  the  placenta  ;  in  embolism, 
etc.  In  some  cases  it  appears  to  be  a  purely  nervous  manifesta- 
tion, following  exhaustion  and  pain. 


PART    VI. 

PATHOLOGY  OF  THE  PUERPERIUM. 


CHAPTER    I. 
SUBINVOLUTION,  SUPERINVOLUTION,  ETC. 

Subinvolution. — When  the  uterus  does  not  undergo  its  nor- 
mal involution  or  reduction  in  size  in  the  weeks  succeeding  labor, 
the  term  "  subinvolution  "  is  applied  to  it.  This  alteration  is  asso- 
ciated with  a  number  of  conditions,  which  probably  act  chiefly 
through  an  alteration  in  the  blood-circulation  in  the  uterus. 
These  may  be  described  as  follows  :  Uterine  and  other  pelvic 
inflammations ;  retained  portions  of  placenta  or  membranes ; 
laceration  of  the  cervix,  followed  by  infection  ;  placental  or  fibrin- 
ous polypi  in  the  uterus  ;  uterine  displacements  ;  all  diseases  caus- 
ing chronic  venous  congestion  in  the  uterus,  among  which  should 
be  mentioned  enteroptosis,  especially  if  associated  with  marked 
separation  of  the  recti  muscles ;  non-lactation ;  too  early  rising 
and  working,  and  too  frequent  pregnancies. 

Subinvolution  is  usually  associated  with  more  or  less  ill  health. 
The  woman  does  not  regain  her  full  vigor,  tires  easily,  and  fre- 
quently complains  of  backache  and  dragging  ;  leukorrhea,  menor- 
rhagia,  and  metrorrhagia  are  common.  On  examination  the  uterus 
is  found  to  be  larger  than  it  should  be,  the  enlargement  being 
uniform. 

Treatment. — Preventive  measures  are  of  the  greatest  impor- 
tance, care  being  taken  to  keep  the  woman  from  the  influence  of 
the  conditions  above  mentioned.  When  subinvolution  is  present, 
therapeutic  measures  should  be  adopted  according  to  the  condi- 
tions found.  If  the  uterus  has  been  imperfectly  emptied,  it  should 
be  thoroughly  curetted.  If  there  be  chronic  renal  or  cardiac  dis- 
ease, causing  venous  congestion,  it  should  be  treated.  The  bowels 
and  bladder  must  be  well  regulated.  Displacements  of  the  uterus 
should  be  rectified,  if  possible.  Local  inflammatory  conditions 
should  be  treated  by  the  well-known  methods.  The  woman  may 
require  to  stop  work  or  to  lessen  it.     Tonics  often   are  beneficiaL 


6o2  SUBINVOLUTION,    SUPERINVOLUTION,    ETC. 

Ergot  is  believed  by  some  to  favor  involution,  by  others  to  retard 
it.     It  may  be  used  in  hemorrhagic  cases. 

Superinvolution. — This  is  the  condition  in  which  the  uterus 
becomes  smaller  than  normal  after  labor.  The  degree  of  atrophy 
varies.  In  the  most  extreme  cases  the  cavity  may  measure  less 
than  an  inch.  A.  R.  Simpson  in  one  instance  found  that  it  was 
reduced  to  \  in.  Usually  the  organ  measures  from  i^  to  2\  in. 
The  atrophy  takes  place  with  varying  rapidity  in  different  cases. 

The  etiology  is  not  definitely  established.  It  has  long  been 
associated  with  the  following  conditions  :  Marked  loss  of  blood  in 
labor ;  exhausting  diseases  ;  excessive  nursing  ;  nervous  derange- 
ments— r.^''.,  puerperal  insanity  ;  and  marked  inflammatory  changes 
in  the  pelvis,  especially  those  interfering  greatly  with  the  ovaries. 

In  most  cases  the  uterine  atrophy  is  only  transitoiy,  being  fol- 
lowed by  a  return  to  the  normal.  In  some  instances,  however, 
the  atrophy  remains  and  menstruation  never  returns,  the  woman 
being  afterward  sterile.  The  latter  must  undoubtedly  be  regarded 
as  cases  of  menopause  induced  by  the  disturbances  connected  with 
the  labor  and  puerperium. 

Vineberg  and  others  have,  however,  noted  that  duiing  lactation 
superinvolution  is  very  frequent  and  should  be  regarded  as  normal, 
being  quite  independent  of  relative  debility  or  anemia.  They  point 
out  that  in  women  who  remain  feeble  after  labor  or  become  weak 
from  any  cause,  and  in  patients  anemic  before  pregnancy,  the 
uterus  tends  to  remain  large.  When  suckling  does  not  occur,  no 
matter  what  the  condition  of  the  woman,  the  uterus  usually  re- 
mains large.  There  can  be  no  doubt  that  a  certain  degree  of 
superinvolution  is  to  be  regarded  as  normal  in  the  lactation  period, 
verification  of  which  may  be  obtained  if  the  uterus  be  measured  in 
a  number  of  cases. 

Anemia. — Normally  after  labor  the  blood  tends  rapidly  to 
return  to  the  normal  condition,  great  progress  being  made  in  the 
first  two  weeks.  In  many  conditions  the  return  is  slow,  while 
frequently  true  anemia  develops.  In  such  cases  the  patient  should 
be  kept  in  bed  longer  than  the  normal  period,  and  should  be  kept 
from  fatigue  or  hard  work  when  she  arises.  The  usual  treatment 
for  anemia  must  be  carried  out.  In  marked  cases  nursing  is  con- 
traindicated. 

Pulmonary  Bnibolism  and  Thrombosis.  —  Pulmonary 
embohsm  has  already  been  described  in  connection  with  labor. 
Though  it  is  rare  under  all  circumstances,  it  is  more  frequent  after 
than  during  labor.  The  emboli  may  arise  from  thrombi  in  the 
uterine  veins  or  other  pelvic  or  thigh  veins,  the  thrombosis  often 
being  associated  with  puerperal  infection.  In  some  cases  the  pul- 
monary arteries  may  be  occluded  by  thrombosis  which  is  primary 
in  them  or  which  extends  from  the  right  heart. 

Systemic  ^^mbolism. — Rarely  in  the  puerperium  portions 


PUERPERAL    HEMORRHAGE.  603 

of  fibrin  may  be  carried  from  the  left  heart  to  one  or  more  arteries 
in  the  brain  or  other  parts  of  the  body.  In  such  cases  there  is 
usually  a  previous  history  of  endocarditis,  rheumatic  fever,  or  sepsis. 

Puerperal  Hemorrhag-e. — This  term  is  applied  to  losses  of 
blood,  in  addition  to  that  which  is  found  in  the  lochial  discharge, 
which  may  occur  at  any  time  in  the  puerperium.  The  hemorrhage 
is  caused  by  various  conditions  : 

Retention  of  Portions  of  the  Placenta  and  Membranes. — 
Pieces  of  the  placenta  may  be  left  in  the  uterus  as  the  result  of  bad 
management  of  the  third  stage.  It  may  result  from  excessive 
compression  of  the  uterus  when  the  placenta  is  attached,  especially 
if  it  be  adherent,  or  it  may  be  due  to  imperfect  removal  by  intra- 
uterine manipulations.  Careful  examination  of  the  placenta  in 
water  after  delivery  should  usually  reveal  the  deficiency  in  its  con- 
tinuity. In  some  cases,  owing  to  abnormality  of  the  placenta, 
portions  may  be  left  in  the  uterus  where  the  greatest  care  is  ex- 
ercised, or  even  where  the  labor  is  entirely  left  to  nature ;  this  is 
due  to  the  existence  of  a  lobed  or  succenturiate  condition  of  the 
placenta.  A  hole  in  the  membranes  near  the  edge  of  the  placenta 
should  always  lead  to  the  suspicion  of  retention  of  such  a  portion. 

Retained  placenta  may  cause  irregular  losses  of  blood  from  the 
uterus,  which  may  be  very  profuse.  In  some  cases,  however,  it 
leads  to  no  hemorrhage.  It  is  frequently  associated  with  puer- 
peral infection,  the  placental  tissue  being  attacked  by  saprophytic 
organisms,  though  in  some  cases  septic  infection  may  also  be 
present.  A  portion  of  membranes  may  also  be  retained,  and  is 
usually  not  suspected  unless  there  be  a  gap  of  considerable  size. 
Any  or  all  the  component  layers  may  be  left.  Some  authorities 
hold  that  retained  membranes  do  not  cause  hemorrhage,  but  the 
statement  is  incorrect ;  bleeding  may  result,  though  it  is  a  rare 
occurrence.  Saprophytic  infection  may  readily  take  place.  Sub- 
involution may  follow.  With  regard  to  the  decidual  portion  of  the 
membranes,  it  is  stated  by  some  that  retention  of  this  alone  may 
lead  to  hemorrhages.  This  is  unlikely,  since  normally  very  little 
of  the  decidua  is  shed  with  the  amniotic  and  chorionic  portions 
of  the  membranes,  the  place  of  separation  being  usually  through 
the  compact  layer,  the  chief  bulk  of  the  decidua  remaining  after 
the  third  stage. 

Treatment. — If  at  the  time  of  labor  it  is  discovered  that  a  piece 
of  placenta  or  a  large  portion  of  membranes  has  been  left  /;/ 
iitero,  it  should  be  removed  by  intra-uterine  manipulations,  carried 
out  with  strict  aseptic  precautions.  The  tissues  can  generally  be 
removed  with  the  fingers.  If  the  uterus  is  too  firmly  contracted, 
it  may  be  necessary  to  employ  dilatation  to  a  certain  extent. 
When  the  fingers  fail  to  remove  the  portions,  curet  forceps  may 
be  employed.  Later  in  the  puerperium  the  latter  is  usually 
necessary. 


604  ^       PUERPERAL   HEMORRHAGE. 

Fibrinous  Polypi. — When  a  portion  of  the  placenta  or  mem- 
branes is  retained,  fibrin  may  be  deposited  upon  it  and  a  poly- 
pus may  gradually  be  formed,  reaching  a  considerable  size. 
It  causes  enlargement  of  the  uterus,  interferes  with  involution, 
and  leads  to  hemorrhage.  If  it  becomes  infected,  a  foul-smelling 
discharge  occurs,  with  symptoms  of  infection.  The  condition 
simulates  malignant  disease.  The  mass,  along  with  the  remains 
of  the  placenta  and  membranes,  should  be  removed  by  the 
curet  forceps  or  the  curet. 

Retention  of  BIood=clots. — When  blood-clots  form  in  the 
uterus  and  are  not  expelled,  owing  to  uterine  relaxation,  displace- 
ments, firm  contraction  of  the  lower  part  of  the  uterus,  or  other 
causes,  fresh  bleeding  may  result  from  the  uterine  vessels.  The 
clots  should  be  removed  either  by  compression  of  the  uterus  or 
by  an  intra-uterine  douche.  Occasionally  it  is  necessary  to  re- 
move them  with  the  fingers. 

Uterine  Displacements. — During  and  after  the  second  week 
prolapse  or  retroversion  of  the  uterus  may  take  place.  Such  dis- 
placements are  especially  found  in  multiparae,  and  are  particularly 
associated  with  excessive  child-bearing,  protracted  or  difficult 
labors,  too  early  rising,  and  walking  or  working.  Retroversion 
and  retroflexion  may  often  be  found  in  normal  cases,  afterward 
disappearing,  the  displacement  being  probably  due  to  the  influence 
of  the  dorsal  position  and  of  a  frequently  distended  bladder.  The 
symptoms  vary  considerably  ;  there  are  backache,  frequency  of 
micturition,  increased  lochial  discharge,  and  irregular  hemor- 
rhages. Clots  may  accumulate  in  the  upper  part  of  the  uterus, 
being  expelled  with  pains.  A  favorable  nidus  for  saprophytic 
infection  is  thus  produced.  The  progress  of  involution  is  impeded. 
In  all  cases  the  displacement  should  be  rectified  as  soon  as 
possible,  and  a  pessary  introduced  into  the  vagina  as  soon  as  it 
can  be  worn.  The  rectum  and  bladder  should  be  regularly 
opened.  After  the  nursing  period  the  question  of  correcting  the 
displacement  by  operative  measures  may  be  considered. 

Puerperal  Infection. — In  infection  of  the  endometrium  it 
occasionally  happens  that  thrombi  closing  the  large  blood-sinuses 
in  the  placental  area  may  be  disintegrated  as  a  result  of  invasion 
by  micro-organisms,  leading  to  the  escape  of  blood.  The  hem- 
orrhages vary  considerably  in  extent.  For  this  condition  a  firm 
intra-uterine  tampon  should  be  used,  ergot  being  given  internally. 
Relaxation  of  the  Uterus. — After  the  first  day  of  the  puer- 
perium  uterine  relaxation  occasionally  takes  place,  causing  hem- 
orrhage. It  may  sometimes  be  due  to  a  sudden  shock  or  great 
emotion.  It  may  occur  in  a  woman  much  weakened  by  an 
exhausting  labor,  loss  of  blood,  disease,  etc.  The  treatment  is 
the  same  as  that  in  cases  of  hemorrhage  occurring  within  the  first 
twenty-four  hours. 


CHORIO-EPITHELIOMA   MA  LIGNUM. 


605 


Retraction  of  the  uterus  may  sometimes  take  place  irregu- 
larly. 

Pelvic  Congestion. — Uterine  hemorrhage  may  be  present  in 
all  conditions  causing  pelvic  congestion — e.g.,  heart,  kidney,  and 
liver  disease  ;  pressure  of  new  growths  ;  inflammations  ;  constipa- 
tion, and  too  early  or  excessive  sexual  intercourse. 

Wounds  in  the  Cervix,  Vagina,  or  Vulva. — Occasionally 
secondary  hemorrhage  may  take  place  from  lacerated  areas  in 
the  lower  genital  tract.  The  tam- 
pon is  usually  sufficient  to  check 
the  bleeding,  though  sometimes 
hgatures  may  be  necessary. 

Hematoma. — Sometimes  hem- 
orrhage may  result  from  the 
bursting  of  a  hematoma  along 
some  part  of  the  genital  tract. 

New  Growths. — Fibromyo- 
mata  of  the  uterus  may  cause 
hemorrhage,  chiefly  by  interfer- 
ing with  the  normal  retraction 
and  contraction  of  the  uterus. 
Carcinoma  or  sarcoma  of  the 
uterus  very  rarely  arises  in  the 
puerperium  and  leads  to  hemor- 
rhage. 

Chorio- epithelioma  Ma- 
lignum. — In  1888  Sanger,  of 
Leipzig,  described  2  cases  in 
which,  after  abortion,  soft,  spongy 
tumors  developed  in  the  uterus, 
with  metastases  in  the  lungs  and 
other  tissues,  leading  to  a  fatal 
issue.  He  believed  the  growths 
to  belong  to  the  sarcomatous 
group,  and  introduced  the  term 
"  deciduoma  malignum  "  to  de- 
scribe them. 

Since  that  time  quite  a  num- 
ber of  similar  cases  have  been  de- 
scribed, and  there  has  been  much 

difference  of  opinion  as  to  their  pathology.  Various  other  names 
have  been  given  to  the  disease — e.  g.,  sarcoma  deciduocellulare, 
sarcoma  choriocellulare,  syncytioma  malignum,  carcinoma  syn- 
cytiale,  etc. 

By  some  the  growths  have  been  regarded  as  fetal,  by  others  as 
maternal,  and  by  others  as  a  mixture  of  both.  There  have  also 
been  differences  of  views  as  to  whether  they  are  of  epiblastic  or 


Fig.  256. — Uterus  with  several  re- 
traction rings  (Bumm) :  a,  Three  re- 
traction rings  in  the  body  of  the  uterus  ; 
b,  ridge  of  os  internum  ;  c,  cervix;  d,  os 
externum. 


6o6  CHORIO-EPITHELIOMA    MA  LIGNUM. 

mesoblastic  origin.  The  term  "  chorio-epithelioma  malignum," 
introduced  by  Marchand,  may  be  regarded  at  the  present  time  as 
the  most  satisfactory  appellation,  for  the  tumors  must  be  regarded 
as  malignant  prohferations  of  the  epiblastic  elements  of  the  chorion 
— viz.,  syncytium  and  Langhans's  cells,  developing  primarily  in 
the  genital  organs  and  secondarily  as  metastases  in  various  other 
tissues.  The  condition  has  been  found  at  all  periods  of  sexual 
life,  mostly  between  twenty  and  thirty.  McCann  has  recently 
reported  a  case  occurring  shortly  after  the  menopause. 

Relation  to  Pregnancy. — The  disease  may  sometimes  begin 
during  pregnancy,  though  usually  it  appears  within  a  few  days, 
weeks,  or  months  after  labor.  MacKenna  states  that  in  the  cases 
collected  by  him  the  average  interval  between  labor  and  the 
earliest  symptoms  was  ten  weeks.  It  has  also  been  stated  that 
rarely  one  or  more  years  ma}'  elapse.  It  may  follow  abortion, 
full-time  labor,  ectopic  pregnancy,  and  hydatidiform  degeneration 
of  the  chorion.  A  considerable  proportion  of  cases  has  been 
described  in  relation  to  the  latter. 

Clinical  Features. — Hemorrhage  is  usually  the  first  and  most 
prominent  symptom  ;  it  is  at  first  irregular,  afterward  becoming 
more  profuse  and  frequent.  A  dirty,  watery  discharge  gradually 
makes  its  appearance.  Weakness  and  cachexia  supervene.  Other 
symptoms  may  be  produced  by  metastatic  developments — c.  g.,  in 
the  vagina,  lungs,  kidneys,  intestines,  liver,  ribs,  etc.  There  is 
often  elevation  of  temperature  and  the  pulse  is  rapid.  In  cases 
following  uterine  pregnancy  the  primary  growth  is  usually  in  the 
uterus,  rarely  in  the  vagina ;  Wehle  has  reported  a  case  of  its 
appearance  in  the  labium.  When  the  disease  begins  in  the  uterus, 
it  forms  a  nodule  in  the  mucosa,  which  is  soon  followed  by  others. 
They  are  soft  and  pliable  and  recur  rapidly  after  curettage.  The 
uterus  is  larger  and  softer  than  usual  on  palpation  and  is  some- 
what tender.  Rarely  the  growth  causes  rupture  of  the  uterine 
wall.  Vaginal  growths  are  recognized  as  soft,  bluish  nodules, 
which  readily  break  down.  The  disease  progresses  rapidly  and  is 
almost  always  fatal,  death  usually  occurring  within  six  months, 
whether  or  not  operative  treatment  be  carried  out. 

Etiology  and  Pathology. — That  these  tumors  are  a  develop- 
ment from  fetal  chorionic  structures  is  now  well  established.  The 
microscopic  appearances  vary  considerabh',  according  to  the  dis- 
tribution and  relationships  of  the  constituent  cells.  Usually  there 
is  a  mixture  of  cells,  derived  both  from  the  syncytium  and  the 
Langhans  layer  of  the  epiblastic  covering  of  the  chorion.  In 
some  cases  the  former  predominate  ;  in  others,  the  latter.  Recently 
growths  have  been  described  consisting  entirely  of  syncytial  ele- 
ments. The  syncytium  consists  of  irregular  masses  of  nucleated 
protoplasm,  often  vacuolated,  the  nuclei  being  rich  in  chromatin, 
somewhat  oval,  their  long  axes  often  being  parallel  to  the  border 


DIAGNOSIS. 


607 


of  the  masses.  Mitoses  are  not  found  in  them.  The  cells  derived 
from  the  Langhans  layer  are  clear  and  mostly  polyhedral,  vary- 
ing in  shape  and  size,  and  do  not  possess  any  intercellular  con- 
nective tissue.  They  contain  glycogen ;  the  nuclei  are  round  or 
oval,  larger  than  those  of  the  syncytium,  and  stain  less  deeply. 
Blood  is  found  around  and  among  the  cell-groups.  Degeneration 
and  necrosis  are  frequently  present  in  the  tissues.  In  another  class 
of  cases,  in  addition  to  these  cellular  elements,  structures  have  been 
found  exactly  resembling  early  villi — i.  e.,  vacuolated  buds  or 
rings  of  epiblast  filled  with  early  mucoid  tissue.     These  have  been 


'v;v«!«:v.:.-^, ,».,. 


'      ''■'''>.< 


Fig.  257. — Portion  of  villus-like  structure  from  vaginal  metastatic  growth.  Case  of 
chorio-epithelioma.  The  proliferated  fetal  epithelium  in  this  portion  is  almost  entirely 
syncytium  (Neumann). 

chiefly  noticed  in  cases  of  hydatid  mole.  Growths  are  carried  by 
the  blood-vessels  ;  they  resemble  the  primary  nodules.  In  the 
description  of  normal  placentation  it  has  been  pointed  out  that 
portions  of  the  fetal  epithelium  are  often  found  in  the  veins  of  the 
uterus,  whence  they  are  carried  into  the  general  circulation  with- 
out causing  any  known  disturbance. 

Diagnosis. — In  the  early  stages  of  the  disease,  before  the  devel- 
opment of  any  large  swelling,  metastases,  or  cachexia,  diagnosis  is 


6o8 


CHORIO-EPITHELIOMA    MA  LIGNUM. 


not  easy.  Loss  of  blood  from  the  genital  tract  in  the  puerperium 
may  be  due  to  various  conditions — c.  g.,  subinvolution,  retained 
portions  of  fetal  tissue,  fibroid  tumors,  etc.  Foul  discharge  may 
also  be  caused  by  infection  of  blood-clot,  fetal  remains,  tumors,  etc. 
Moreover,  sarcoma  or  carcinoma  of  the  maternal  tissues  may  cause 
these  changes. 

In  every  case  the  most  thorough  physical  examination  of  the 
genitalia  must  be  made,  the  interior  of  the  uterus  being  explored 
by  the  fingers.  Abnormal  projections  of  tissue  should  be  removed 
and  examined  microscopically.  If  marked  proliferation  of  the  syn- 
cytium and  Langhans's  cells  be  found,  especially  in  a  nodule,  the 
suspicion  of  the  existence  of  chorio-epithelioma  malignum  is  very 
strong.  In  difficult  cases  the  opinion  of  one  who  is  an  expert  in 
the  microscopic  study  of  the  uterus  and  its  contents  during  preg- 
nancy is  of  the  greatest  value,  for  it  must  be  remembered  that  after 


Fig.   258. — Portion  of   chorio-epithelioma,  highly  magnified   (von   Franque) :    a,   Syn- 
cytium ;  ir,  Langhans's  cells  ;  c,  space  containing  blood. 

abortion,  hydatid  mole,  and  full-time  labor,  scrapings  of  the  uterine 
mucosa  may  contain  different  chorionic  elements  that  have  not 
been  expelled  at  birth,  and  these  might  easily  be  regarded  as 
chorio-epithelioma  malignum  by  inexperienced  observers.  More- 
over, decidual  cells  may  also  be  found  in  the  scrapings,  and  these 
may  sometimes  be  very  difficult  to  distinguish  from  the  chorionic 
epithelial  elements,  especially  the  proHferated  Langhans's  cells  of 
the  malignant  growth. 

As  Pierce  states,  extreme  caution  must  be  used,  especially  in 
the  case  of  a  young  woman.  He  advises  that  if  the  examination 
of  the  first  scrapings  is  not  conclusive,  the  patient  be  kept  under 
observation  a  short  time  and  curetted  again.  If  malignancy  be 
present,  increased  proliferation  of  the  cells  will  be  found  ;  if  not,  a 
small  quantity  of  the  cells  or  none  at  all  will  be  detected.     After 


TREATMENT. 


609 


curettage  the  malignant  growth  usually  rapidly  recurs.  Thus, 
Marchand  reports  a  case  where  five  days  after  thorough  curettage 
the  uterus  was  again  filled. 

The  disease  may  be  difBcult  to  distinguish  from  carcinoma  or 
sarcoma  of  the  maternal  tissues.  In  the  latter  growths  true  syn- 
cytium or  structures  resembling  early  villi  are  not  found.  Giant 
cells  may,  however,  sometimes  resemble  portions  of  syncytium. 
Chorio-epithelioma  has  no  stroma,  differing  from  carcinoma ;  the 
latter  disease  is  carried  by  the  lymphatics,  and  the  metastases  de- 
velop more  slowly  than  in  the  case  of  chorio-epithelioma.  Only 
rarely  are  the  lymphatic  glands  involved  in  chorio-epithelioma. 
Liver  metastases  are  more  common   in   sarcoma  and  carcinoma. 


V  — 


Fig.  259. — Section  of  vein  in  outer  part  of  uterine  musculature  containing  a  villus- 
like  structure  with  greatly  hypertrophied  epithelium.  Case  of  chorio-epithelioma  fol- 
lowing hydatidiform  mole  (Neumann)  :  v.  Wall  of  vein  ;  c,  connective  tissue  of  villus; 
s,  syncytium  ;  L,  Langhans's  cells. 


Carcinoma  mostly  occurs  after  forty ;  chorio-epithelioma  before 
thirty. 

Treatment. — Only  one  form  of  treatment  is  advisable — viz., 
total  extirpation  of  the  uterus,  when  the  disease  begins  in  this 
organ,  and  of  the  uterus  and  vagina  when  it  begins  in  the  latter. 
Owing  to  the  frequency  of  the  disease  after  hydatid  mole,  Ries- 
mann  advises  routine  curettage  of  the  uterus  ten  to  fourteen  days 
after  expulsion  of  the  mole.  If  proliferation  of  the  chorionic  epi- 
thehum  be  found,  he  removes  the  uterus. 

As  regards  the  method  of  extirpation  of  the  uterus,  Pierce 
rightly  advises  the  abdominal  route,  because  the  organ  maybe  re- 
moved with  less  disturbance  than  when  the  vaginal   operation  is 


6lO  .  CHANGES  IN  THE    URINE. 

chosen.  He  points  out  that  manipulations  of  the  uterus  are  apt 
to  force  fragments  of  the  uterine  growth  into  the  veins,  thus  in- 
creasing the  risk  of  metastatic  development. 

When  the  abdomen  is  opened,  the  first  step  in  the  operation 
should  be  ligation  or  clamping  of  the  uterine  and  ovarian  vessels 
before  the  uterus  is  handled. 

When  metastases  have  developed  in  the  vagina,  following  a 
primary  growth  in  the  uterus,  total  extirpation  is  likely  to  be  soon 
followed  by  developments  in  other  parts  of  the  body.  Distant 
metastases,  indeed,  indicate  that  treatment  can  only  be  palliative. 

Blevation  of  Temperature. — Various  references  have  been 
made  to  rises  of  temperature  in  the  puerperium.  The  causes  may 
be  recapitulated  as  follows  : 

1.  Infection  through  the  genital  tract  at  or  after  labor. 

2.  Infection  of  some  other  part  of  the  body — c.  g.,  mamma, 
bladder,  etc. 

3.  The  presence  of  a  local  inflammatory  process  antedating 
the  labor. 

4.  Specific  diseases  developing  before  or  after  labor — c.  g., 
typhoid,  pneumonia,  malaria,  syphilis,  scarlet  fever,  influenza,  etc. 

5.  Constipation  and  intestinal  intoxication. 

6.  Various  non-infective  conditions  :  Shock  or  emotional  dis- 
turbances ;  severe  after-pains ;  exposure  to  chill ;  interference 
with  the  free  flow  of  milk  in  the  milk  ducts,  leading  to  accumu- 
lation ;  rapid  distention  of  the  breasts,  causing  distress  in  the 
latter. 

Puerperal  Rashes. — Erythematous  rashes  distributed  over 
wide  or  small  areas  may  be  associated  with  puerperal  infection. 
They  may  resemble  the  eruption  of  scarlet  fever  very  closely.  It 
has  been  suggested  that  in  some  cases  these  rashes  are  due  to  a 
specific  organism.  Sometimes  more  serious  skin  eruptions  may 
result  from  puerperal  infection — e.  g.,  bullous  formation.  Occa- 
sionally skin  eruptions  are  due  to  the  influence  of  articles  of  diet. 
They  may  be  due  to  various  diseases — r.  ^.,  scarlet  fever,  measles, 
erysipelas,  small-pox,  etc.  In  some  cases  the  skin  eruption  may 
be  the  exacerbation  of  an  old  trouble — c.  g.,  eczema. 

Changfes  in  the  Urine. — The  normal  constituents  of  the 
urine  have  already  been  described  (p.  269).  Albumin  sometimes 
appears  as  a  temporary  and  quickly  passing  phase.  In  some 
cases  albuminuria  is  the  continuation  of  a  condition  existing 
before  labor.  It  may  be  due  to  an  inflammation  in  any  part  of 
the  urinary  tract  or  to  the  presence  of  blood.  Sometimes  it  is 
due  to  degeneration  of  the  renal  epithelium  following  labor  ; 
sometimes  to  a  true  nephritis.  It  is  frequently  found  in  puerperal 
sepsis. 

Blood  in  the  urine  in  the  puerperium  may  be  due  to  injuiy 
to  the  urethra  or  bladder  during  labor,  and  occasionally  to  vesical 


DISTURBANCES   OF   URINATION.  6ll 

hemorrhoids  ;  sometimes  to  acute  septic  infection.  It  may  also 
be  caused  by  various  conditions  entirely  independent  of  preg- 
nancy— c.  g.,  calculus,  new  growth,  etc. 

Disturbances  of  Urination. — Retention  of  the  urine  in 
the  puerperium  may  be  due  to  paresis  of  the  bladder-wall  or  to 
interference  with  the  nervous  mechanism  regulating  the  sphincter 
of  the  urethra ;  the  latter  may  also  be  reflexly  stimulated.  Some- 
times the  urethra  is  pressed  against  the  pubes  by  the  uterus  ; 
sometimes  its  mucous  membrane  is  swollen  from  injury  in  labor. 

Incontinence  of  tlie  urine  may  be  due  to  paresis  of  the 
sphincter,  to  dribbling  from  an  overdistended  bladder,  or  to  a 
fistulous  communication  established  between  the  bladder  or  ureter 
and  the  cervix  or  vagina.  When  vesicovaginal  fistula  is  produced 
as  the  result  of  laceration,  the  incontinence  is  usually  present  from 
the  beginning  of  the  puerperium.  When  it  is  due  to  necrosis  fol- 
lowing prolonged  pressure  in  labor,  it  does  not  begin  until  two  or 
more  days  have  passed  after  labor. 

Suppression  of  the  Urine. — Apart  from  eclampsia  and 
Bright's  disease,  suppression  of  the  urine  following  labor  is  very 
rare,  yet  it  may  occur  completely  or  partially  in  women  who  have 
not  suffered  from  these  troubles.  Recently  a  few  such  cases  have 
been  recorded  by  McKerron,  Boxall,  and  others.  In  most  of  these 
the  age  of  the  women  was  under  thirty.  The  labors  were  mostly 
premature,  and  the  fetus  was  dead  in  the  majority  of  cases.  In 
most  cases  during  the  period  of  suppression  the  symptoms  were 
not  marked,  the  patient  feeling  fairly  comfortable.  Headache, 
pain  in  the  back,  and  vomiting  were  usually  present.  The  fatal 
cases  developed  drowsiness,  coma,  and  muscular  twitchings.  In 
two,  convulsions  were  noted  before  death.  In  the  fatal  cases 
scarcely  any  urine  could  be  obtained ;  it  contained  albumin,  casts, 
and  blood.  It  is  unfortunate  that  careful  examination  of  the 
urine  was  not  made  in  these  cases  during  pregnancy.  In  most 
of  them  there  was  nothing  unusual  in  the  clinical  symptoms.  It 
is  probable  that  renal  insufficiency  was  present  before  labor,  and 
that  the  influence  of  the  delivery  acted  in  precipitating  the  anuria. 
In  cases  of  neurotic  women  the  condition  may  possibly  sometimes 
be  akin  to  hysteric  suppression. 

Cystitis. — Infection  in  the  bladder  in  the  puerperium  is  gen- 
erally due  to  carelessness  in  technic,  catheterization  frequently 
being  responsible.  Sometimes  it  is  part  of  an  infective  process 
that  affects  the  genital  tract.  Occasionally  it  may  be  an  exacerba- 
tion of  an  old  cystitis  or  may  develop  from  an  old  uncured 
urethritis.  There  is  a  great  tendency  in  these  cases  to  an  upward 
infection  of  the  whole  urinary  tract.  Various  organisms  are  found 
in  cystitis,  the  colon  bacillus  being  one  of  the  most  frequent. 
The  infective  process  occurs  with  varying  intensity  in  different 
cases.     Rarely  large  portions  of  the  mucosa  may  be  exfoliated, 


6l2  •,  PUERPERAL   NEURITIS. 

and  sometimes  a  large  portion  of  the  bladder-wall  may  become 
gangrenous  and  slough  away. 

Injuries  to  Nerves. — In  cases  of  instrumental  or  difficult 
labor,  especially  in  contracted  pelvis,  various  nerves  may  be 
injured.  Pain  may  be  felt  in  the  sacral  region  during  defecation 
or  when  the  vagina  or  rectum  is  examined  and  pressure  is  made 
against  the  sacrum ;  it  may  be  aggravated  on  movement.  In 
some  cases  pains  in  the  lower  limb  may  be  marked  in  relation  to 
one  or  more  nerve-trunks.  Paresis  or  paralysis  of  one  or  more 
groups  of  muscles  in  one  or  both  lower  extremities  may  also 
result  from  nerve  injury;  considerable  atrophy  may  also  take 
place.  The  skin  is  frequently  affected,  so  that  areas  of  anesthesia 
or  hyperesthesia  are  produced.  Occasionally  inflammatoiy  changes 
may  take  place  in  some  of  the  affected  nerves. 

Puerperal  Neuritis. — Neuritis  may  develop  after  childbirth, 
or  may  appear  in  the  puerperium  as  a  continuation  of  an  affection 
that  began  during  pregnancy.  It  may  occur  as  a  generalized  or 
a  localized  condition.  According  to  Bayle,  the  first  form  mani- 
fests itself  chiefly  during  pregnancy,  being  preceded  by  severe 
vomiting.  The  disease  is  preceded  by  pyrexia,  and  usually  runs 
a  rapid  course,  tingling,  shooting  pains,  itching,  feeling  of  cold, 
heat,  etc.,  evidence  of  changes  in  peripheral  nerves,  soon  develop- 
ing. These  are  followed  by  numbness  and  signs  of  paralysis  in 
the  upper  or  lower  limbs,  abdominal,  laiyngeal,  or  pharyngeal 
muscles.  Usually  the  weakness  affects  the  lower  limbs  first. 
The  respiratoiy  and  cardiac  muscles  usually  escape,  and  the 
bladder  and  rectum  are  rareh*  invoh-ed.  Patients  become  irritable, 
restless,  and  depressed.  There  may  be  hallucinations  or  delirium. 
This  generalized  form  of  neuritis  progresses  for  years.  If  re- 
covery takes  place,  a  relapse  is  likely  to  occur.  The  prognosis  is 
fairly  favorable,  though  sometimes  there  is  an  early  fatal  termina- 
tion. 

In  the  localized  form  of  neuritis  different  areas  may  be  affected. 
Thus,  one  or  both  arms  may  be  involved  in  various  degrees,  or 
the  lower  extremities  may  be  affected.  When  the  latter  are  in 
the  stage  of  paralysis,  the  condition  may  be  mistaken  for  traumatic 
paralysis  due  to  injury  caused  by  labor.  The  history  of  preceding 
sensory  disturbances,  and  usually  of  septic  infection,  suffices  to 
establish  the  diagnosis  of  neuritis. 

The  disease  is  probably  due  to  toxic  influences.  It  may  be 
caused  by  toxins  produced  in  the  body  during  pregnancy  or  re- 
sulting from  infection  at  or  after  labor.  Mobius  and  Tuilant  have 
shown  that  it  is  the  homologue  of  the  neuritis  that  follows  ery- 
sipelas, typhoid,  small-pox,  and  other  diseases.  Anemia,  exhaus- 
tion, and  psychic  disturbances  may  favor  the  development  of 
the  disease.  The  treatment  is  that  carried  out  in  non-puerperal 
neuritis.     Bayle  recommends  the  use  of  ergotin. 


PUERPERAL    TETANUS.  613 

Meyer  has  reported  17  cases  of  anterior  crural  neuritis  occur- 
ring in  1000  patients  in  the  Copenhagen  Lying-in  Hospital.  In 
none  of  these  was  there  any  sign  of  puerp&ral  infection.  The 
anterior  crural  nerve  is  not  subjected  to  pressure  during  labor. 
In  7  of  the  cases  the  neuritis  was  bilateral. 

Puerperal  Insanity. — The  minor  and  serious  mental  dis- 
turbances that  may  complicate  pregnancy  have  already  been 
described  (p.  286).  Insanity  may  also  develop  during  the  puer- 
perium  and  much  more  frequently.  Clouston  states  that  i  in  every 
400  labors  is  followed  by  it.  In  50  per  cent,  of  cases  it  begins 
within  the  first  week,  and  in  80  per  cent,  within  the  first  two 
weeks.  The  most  acute  cases  are  those  developing  in  the  first 
fortnight.     It  is  more  frequent  in  primiparae. 

Etiology. — Frequently  there  is  a  predisposing  cause — e.  g.^ 
bad  heredity  and  prolonged  mental  or  physical  strain.  Anemia, 
sepsis,  albuminuria,  marked  emotional  disturbance,  and  the  pains 
and  excitement  of  labor  are  often  factors  in  its  production. 

Symptoms. — The  onset  is  usually  sudden.  The  woman  may 
take  no  interest  in  her  baby  or  husband,  may  lose  appetite,  and 
get  sleepless.  She  may  take  violent  dislikes,  become  excitable, 
incoherent,  and  violent.  There  may  be  a  suicidal  or  homicidal 
tendency.  The  pulse  gets  weak  and  the  temperature  rises.  In 
most  cases  the  type  of  insanity  is  maniacal  ;  in  other  cases  there 
are  melancholia,  lethargy,  and  stupor.  In  some  cases  there  is 
marked  delirium ;  in  mild  cases  marked  depression  is  frequent. 
Often  during  the  course  of  an  attack  there  are  variations  in  the 
manifestations.  An  acute  insane  attack  must  be  diagnosed  from 
the  occasional  temporary  hysteric  outbreaks  of  labor,  alcoholic 
delirium,  and  mental  disturbances  of  puerperal  infection. 

Prognosis. — The  disease  is  curable  and  relapses  are  rare. 
Clouston  has  reported  75  per  cent,  of  recoveries  in  his  cases, 
generally  rapid ;  one-half  of  the  patients  being  well  in  three 
months,  and  90  per  cent,  within  six  months.  Occasionally  re- 
covery takes  place  after  years  of  impaired  mentality.  There  is 
probably  a  larger  number  of  recoveries  in  acute  and  severe  cases 
than  in  mild  ones. 

Treatment  is  best  carried  out  in  an  asylum.  If,  however,  the 
patient  be  kept  at  home,  skilled  nurses  should  be  constantly  in 
attendance  on  her. 

Puerperal  Myelitis. — Rarely  myelitis  may  develop  after 
labor,  usually  beginning  during  the  second  week,  with  impairment 
of  sensation  and  motion  in  the  lower  extremities  and  incontinence 
or  retention  of  urine.  Spastic  paralysis  may  become  well  marked. 
The  disease  is  probably  caused  by  septic  infection. 

Puerperal  Tetanus. — This  subject  has  already  been  noted. 
f.See  p.  288.)  The  treatment  is  very  unsatisfactory.  The  uterus 
has  been   several  times  extirpated  in  the  hope  of  preventing  the 


6 14  DISTURBANCES  IN    THE   BREASTS. 

extension  of  the  disease,  but  usually  with  unsatisfactory  results. 
The  antitoxin  should  always  be  tried. 

Puerperal  Tetany. — This  condition  has  very  rarely  been 
reported.  It  is  generally  one  of  a  number  of  hysteric  manifesta- 
tions. 

Puerperal  Gangrene. — This  condition  is  very  rare  ;  it  may 
be  due  to  embolism  associated  with  heart  disease  that  existed 
before  the  pregnancy  or  developed  during  its  course  or  in  the  puer- 
perium.  It  may  result  from  thrombosis  due  to  various  causes  ; 
sometimes  it  occurs  in  phlegmasia  alba  dolens.  In  a  few  instances 
it  has  been  due  to  Raynaud's  disease.  In  a  number  of  cases  the 
etiology  is  obscure.  The  prognosis  is  fairly  good  in  the  dry 
forms,  but  is  bad  in  the  moist  and  septic  varieties.  In  the 
former  amputation  may  be  deferred  until  a  line  of  demarcation 
has  formed  ;  in  the  latter  it  should  be  performed  immediately,  well 
above  the  disease. 

Disturbances  in  the  Breasts. — Anomalies. — Absence  of 
one  or  both  breasts  is  a  rare  occurrence.  Partial  de\'elopment  is 
common.  Extreme  hypertroph}'  is  rare  and  may  be  more  marked 
on  one  side  than  on  the  other.  Supernumerary  breasts  and  nipples 
are  not  infrequent ;  they  are  usually  below  the  proper  breasts,  but 
maybe  on  any  part  of  the  trunk — e.g.,  back,  axilla,  buttocks,  ab- 
domen, and  external  genitals.  The  nipples  ma}'  be  defective,  due 
to  congenital  or  acquired  causes  ;  they  ma\'  be  abnormally  small, 
depressed,  inverted,  or  irregularh'  shaped.  In  some  cases  the  child 
is  not  able  to  use  the  nipple  without  the  use  of  a  nipple-shield. 
Sometimes  it  cannot  be  used  even  in  this  manner. 

Defective  Milk  Secretion. — Deficiency  of  milk  secretion  is  not 
infrequent.  Complete  absence  is  extremely  rare  apart  from 
absence  of  the  breasts.  The  conditions  that  fa\or  defective  milk 
secretion  are  faulty  mammary  development,  child-bearing  at  an 
extremely  early  or  advanced  age,  exhausting  diseases,  mastitis, 
obesity,  poor  nutrition,  and  emotional  disturbances.  Altmann  has 
pointed  out  that  in  certain  districts  in  Europe,  where  it  has  long 
been  customary  to  feed  infants  artificially,  there  is  a  congenital 
form  of  atrophy  of  the  breasts  in  the  women. 

Treatment  is  unsatisfactory  except  where  the  deficiency  is  due 
to  general  conditions.  In  these  cases,  by  judicious  dieting  and 
tonics,  the  mammary  function  may  be  improved.  Plenty  of  fluids 
should  be  given,  especially  milk  ;  fluid  extract  of  malt  is  also 
valuable. 

Polygalactia. — Exces.sive  milk  secretion  during  lactation  is 
occasionally  found  in  healthy,  well- nourished  women.  In  such 
cases  the  fluids  in  the  diet  should  be  reduced.  The  bowels  must 
be  regularly  moved.  If  necessary,  some  milk  may  be  drawn  from 
the  breasts  in  addition  to  what  the  infant  sucks. 

Galactorrhea. — This   term   is   applied   to   cases  in  which  the 


DISTURBANCES  IN   THE   BREASTS. 


6l 


milk  runs  from  the  nipples  when  the  child  is  not  nursing,  and  to 
those  in  which  it  flows  after  weaning.  The  condition  may  be  very 
distressing  to  the  woman  and  tends  to  reduce  her  strength.  It 
has  been  known  to  last  for  years. 

The  treatment  during  the  nursing  period  should  consist  in  strict 
reduction  of  fluids  in  the  diet,  and  in  the  application  of  firm  breast- 
binders.  The  bowels  should  be  kept  open.  After  weaning,  iodid 
of  potassium  may  be  given  internally,  and  atropin  may  also  be 
used  if  necessary. 

Hyperlactation. — Prolongation  of  the  nursing  period  is  fre- 
quent among  women,  who  try  thereby  to  prevent  conception.     In 


Fig.  260. — Modified  Murphy  breast-binder  (Dickinson). 

some  countries — e.g.,  Japan — it  is  customary  to  nurse  two  or  more 
years.  The  practice  is  an  evil  one,  as  it  usually  leads  to  dete- 
rioration of  the  mother's  health.  Anemia,  loss  of  weight  and 
strength,  and  neurasthenia  frequently  result. 

Qalactocele. — This  is  the  distention  of  a  mammar}-  acinus  with 
milk.  It  is  due  to  congenital  absence,  stenosis,  or  atresia  of  the 
duct,  or  may  result  from  inflammation  ;  it  may  be  single  or  mul- 
tiple. In  some  cases  the  cyst  shrinks  and  causes  no  trouble. 
When  it  tends  to  enlarge,  it  is  advisable  to  open  and  drain  it,  or  to 
dissect  out  the  lining-. 


6i6 


DEFECTIVE    QUALITY   OF   THE   MILK. 


Defective  Quality  of  the  Milk. — The  milk  is  liable  to  many 
qualitative  variations  that  may  affect  the  health  of  the  child,  apart 
from  those  normally  present  at  different  periods  of  lactation. 
Occasionally  an  apparently  healthy  woman  produces  milk  that 
disagrees  with  the  infant,  the  cause  being  undetermined.  Lack  of 
exercise,  emotional  excitement,  and  many  drugs  and  diseased  con- 
ditions impair  the  quality  of  the  milk,  though  the  nature  of  the 
change  may  not  be  known. 

Peculiarities  of  diet  exercise  an  important  influence.  Excess  in 
nitrogenous  diet  tends  to  increase  the  fat  and  casein  in  milk,  while 
a  fatty  diet  tends  to  diminish  them.  A  vegetable  diet  increases 
the  sugar  and  diminishes  the  fat  and  casein.  Defective  diet 
diminishes  all  the  milk  solids  except  albumin.  Excess  of  proteids 
in  the  milk  often  causes  trouble  to  the  child.     Rotch  points  out 


s 

4 

n 

s 

4 

5 

1 

1 

/ 

1        "        / 
!                   1 

/    s    \ 

1                        \ 

1 

V 

/ 

\ 
% 

1 
\ 

6 

1 

\ 
\ 

\ 
\ 

10 


40  incheb 
Fig.  261. — Modified  Murphy  breast  binder  (cut  on  dotted  lines). 


that  disturbances  miay  be  caused  by  a  too  abundant  diet  and  in- 
sufficient exercise.  Frequently  there  are  excessive  casein  and  defi- 
cient fat.  Emotional  disturbance  often  leads  to  an  increase  in 
proteids,  which  disturb  digestion.  Rotch  gives  the  following  table 
of  variations  : 


NoRM.\L    jMiLK. 

Normal  exercise 
and  food. 


Fat     .... 

Proteids     .    . 

Sugar     .    .    . 

Ash    .... 
Total  solids 
Water    .    . 


4.0 
1.2 
7.0 
0.2 
12.40 
87.60 


^OOR  Milk. 

Very  rich  M 

LK. 

Bad  Milk. 

Starvation. 

Generous  diet ; 
exercise. 

little 

Pregnancy, 
disease,  etc. 

1.50 

5.10 

o.So 

2.40 

3-50    , 

4-50 

4.00 

7-50 

5.00 

0.09 

0.25 

c.p9 

7-99 
92.01 

16.35 
83-65 

10.39 
89.61 

100.00 

100.00 

100.00 

Angel  Money  states  that  a  poor  milk  may  be  improved  by 
recrulatino;  the  mother's  diet,  giving  more  meat  and  milk,  diminish- 
ing  exercise,  lessening  the  intervals  of  nursing,  and  reducing  the 
quantity  of  fluids.     Rich  milk  may  be  diluted  by  increasing  the 


DISTURBANCES  IN   THE   BREASTS.  617 

intervals  of  nursing,  decreasing  the  amount  of  meat,  increasing 
exercise,  and  augmenting  the  quantity  of  fluids  drunk.  He  points 
out  the  widespread  error  of  beheving  that  beef  broth  and  chicken 
tea  are  valuable  for  nursing  women,  or  that  ale  and  porter  improve 
milk.  Purgation  of  the  mother  should  not  be  employed  to  alter 
the  character  of  the  milk.  In  regulating  the  bowels,  dieting, 
massage,  and  exercise  are  better  than  laxatives. 

All  diseased  conditions  may  affect  the  milk.  In  acute  febrile 
and  toxic  disturbances  the  change  may  be  marked.  For  this  reason 
nursing  should  be  discontinued  in  puerperal  infection.  Moreover, 
it  should  be  borne  in  mind  that  the  septic  organisms  may  be  found 
in  the  milk  and  may  infect  the  child.  Tubercle  bacilli  and  also 
other  organisms  may  be  transmitted.  In  the  early  stages  of  a 
febrile  condition  there  may  be  a  marked  diminution  of  the  mam- 
mary function  for  several  hours.  While  it  is  in  progress,  men- 
struation may  sometimes  affect  the  quality  of  the  milk,  but  fre- 
quently the  child  is  in  no  way  disturbed. 

Colostrum  corpuscles  sometimes  appear  in  the  milk  during 
lactation — i.  c,  when  menstruation  or  any  acute  affection  occurs. 
It  is  held  by  some  that  if  they  are  present  after  two  weeks'  nursing 
the  formation  of  milk  is  defective.  They  may  be  found  occa- 
sionally months  or  even  years  after  child-bearing  or  nursing. 
They  are,  therefore,  no  proof  of  recent  delivery. 

Sore  Nipples. — In  a  considerable  percentage  of  nursing  women 
the  nipples  are  a  source  of  trouble,  generally  within  the  first  few 
days  following  labor.  Various  changes  are  found — r.^.,  erythema, 
fissures,  maceration,  vesicular  formation,  erosions,  and  ulceration. 

These  conditions  are  mostly  the  result  of  careless  management 
of  the  breasts  during  the  later  weeks  of  pregnancy.  If  the  colos- 
trum be  allowed  to  cake,  dirt  accumulates  and  infection  may  follow. 
This  is  especially  apt  to  occur  if  the  nipples  are  irritated  by  the 
pressure  of  the  clothing.  When  nursing  begins,  milk  oozing  from 
the  nipples  and  allowed  to  saturate  the  clothes  may  lead  to  soften- 
ing of  the  epithelium ;  as  a  result,  vesicles  may  form  and  burst, 
giving  rise  to  erosions.  These  may  deepen  and  become  ulcers! 
Sometimes  these  areas  become  infected  from  aphthous  patches  in 
the  infant's  mouth,  Fissures  may  be  caused  by  the  compression 
of  clothing  or  may  develop  from  the  erosions  just  described. 
.Sometim.es  they  follow  the  tearing  away  of  a  portion  of  encrusted 
colostrum  along  with  the  subjacent  epithehum.  They  occur 
usually  at  the  base  of  the  nipple,  but  they  may  be  found  on  the 
projecting  portion.  When  milk-ducts  open  into  the  base  of  a 
fissure  or  ulcer,  they  are  apt  to  be  occluded  as  the  latter  heals. 
These  lesions  of  the  nipples  are  a  source  of  distress  and  pain  to 
the  woman  while  the  child  nurses,  and  they  are  important  as 
affording  a  place  of  entrance  for  infective  organisms,  which  may 
give  rise  to  mastitis. 


6l8  MASTITIS. 

Treatment. — Prophylactic  care  of  the  breasts  during  pregnancy 
is  important.  They  should  not  be  compressed  by  clothes  or 
corset.  The  nipples  should  be  carefully  cleansed  each  day.  They 
should  not  be  allowed  to  rest  against  soiled  clothing,  nor  should 
colostrum  be  allowed  to  gather  on  them.  For  cleansing  purposes 
borax  and  water  or  mild  soap  and  water  suffice.  Hardening 
agents  are  not  necessary — e.  g.,  alcohol ;  they  are  likely  to  lead  to 
cracking  of  the  epithelium.  When  the  nipples  are  small  or  de- 
pressed, it  is  advisable  to  use  massage  during  the  last  two  or  three 
months.  The  nipple  should  be  well  soaked  in  lanolin  or  fresh 
cocoa-butter  at  bedtime,  being  kneaded  and  drawn  out  by  fingers 
that  have  been  well  scrubbed.  In  this  way  they  may  be  enlarged 
and  prepared  for  the  irritation  caused  by  suckling.  The  daily  ap- 
plication of  a  breast-pump  serves  the  same  purpose. 

When  the  nursing  begins  the  nipples  must  be  carefully  pro- 
tected. During  the  first  {q.\n  months  it  is  advisable  to  wash  the 
nipple  with  boric  lotion  (saturated)  and  boiled  water  before  and 
after  nursing.  Between  the  times  of  suckling  olive  oil  may  be 
applied  to  the  nipples.  The  infant's  mouth  must  be  regularly  in- 
spected, and  also  cleansed  with  boric  lotion  if  it  is  not  perfectly 
healthy. 

Curative  Treatment. — When  a  fissure,  excoriation,  or  ulceration 
is  present,  the  nipple  should  be  well  protected  by  antiseptic  solu- 
tions or  ointments.  The  compound  tincture  of  benzoin  is  often 
satisfactory,  applied  once  or  twice  a  day ;  Lassar's  paste  is  also 
serviceable.  If  the  child  suckles,  these  applications  must  be  washed 
away  before  it  takes  the  nipple.  When  the  nipple  is  painful 
during  nursing,  a  sterile  cocain  solution  may  be  applied  to  it  five 
minutes  before  the  act,  the  nipple  being  washed  in  sterile  water 
before  the  child  suckles.  Very  painful  fissures  sometimes  require 
the  application  of  silver  nitrate,  the  area  being  made  anesthetic 
beforehand  by  cocain,  the  breasts  being  rested  for  a  few  days  after- 
ward. It  is  often  advisable  to  use  a  nipple-shield,  but  if  the  child 
refuses  to  take  it  or  the  pain  is  still  excessive,  nursing  should  be 
discontinued  on  the  affected  side  for  a  few  days,  and  the  breast 
should  be  relieved  by  stroking  it  from  base  to  apex  or  by  the  use 
of  a  breast-pump.  When  a  nipple  shield  or  breast-pump  is  used, 
it  should  be  boiled  beforehand. 

If  both  nipples  are  affected,  the  intervals  between  nursing  should 
be  made  as  long  as  possible,  or  each  breast  may  be  rested  on 
alternate  days.  Rarely  it  may  be  necessary  to  wean  the  child 
before  the  nipple  lesions  can  be  cured. 

Mastitis. — Inflammation  occurs  in  about  6  per  cent,  of  nursing 
women,  and  usually  begins  within  a  month  after  delivery.  The 
lesion  is  due  to  infection  by  various  micro-organisms,  Staphylo- 
coccus aureus  and  albus  being  most  frequently  found.  Streptococcus 
and  other  septic  germs  may  occasionally  be  the  active  agents.     In 


DISTURBANCES   IN   THE   BREASTS.  619 

most  cases  the  infection  is  derived  from  external  sources — /.  c, 
dirty  or  diseased  nipples,  unclean  clothing,  fingers,  or  applications, 
and  the  infant's  diseased  mouth. 

The  organisms  usually  enter  the  milk-ducts,  though  they  may 
spread  directly  to  the  subcutaneous  tissue  by  the  lymphatics  when 
the  skin  is  injured.  Recent  researches  appear  to  show  that 
microbes  are  often  found  in  the  milk-ducts  of  women  who  are 
healthy  and  whose  breasts  are  normal.  Indeed,  Honigman  and 
Ringel  state  that  the  milk  normally  contains  the  Staphylococcus 
aureus  and  albus.  Kostlin  has  studied  bacteriologically  the  milk 
from  100  pregnant  and  137  puerperal  women.  Micro-organisms 
were  found  in  86  per  cent,  of  the  former  and  in  91  per  cent,  of  the 
latter.  With  'i^'^  exceptions  they  were  staphylococci,  the  Staph- 
ylococcus albus  being  most  common.  This  being  the  case,  it  is 
probable  that  other  factors  are  necessary  before  a  mastitis  can 
develop.  These  may  be  found  in  conditions  of  impaired  general 
health,  local  injury  to  the  breast — /.  e.,  injudicious  massage  or  use 
of  the  breast-pump,  superficial  excoriation,  etc.  Many  hold  that 
milk  stasis  may  sometimes  play  a  part  by  distending  the  milk 
cartals  and  possibly  injuring  the  lining  membrane.  It  is  generally 
believed  that  in  cases  in  which  a  septic  process  is  present  in  some 
other  part  of  the  body — e.  g.,  septic  endometritis — the  organisms  may 
pass  from  the  blood  into  the  milk  canals  of  the  breasts,  and  may  some- 
times lead  to  breast  infection.  It  may  be  considered  as  almost  certain 
that  mastitis  does  not  occur  without  the  agency  of  micro-organisms. 

Varieties. — Mastitis  is  found  in  three  varieties — viz.,  subcuta- 
neous, glandular,  and  submammary.  These  may  occur  singly  or 
combined.  The  subcutaneous  tissue  over  any  part  of  the  breast 
may  be  affected,  though  the  areola  is  a  frequent  site.  All  stages 
of  inflammation  may  be  found.  When  the  areola  is  affected,  the 
infection  may  occur  around  the  sebaceous  folHcles,  giving  rise  to 
small  boils,  or  may  be  diffuse ;  suppuration  frequently  occurs  and 
may  lead  to  fistulous  communication  with  the  milk-ducts. 

When  the  glandular  tissue  is  affected,  the  inflammatory  process 
may  occur  in  one  or  more  areas,  forming  tender  thickenings.  The 
interglandular  connective  tissue  is  usually  involved.  All  stages  of 
inflammation  may  be  found.  As  a  result  milk-ducts  may  be  con- 
stricted or  closed,  the  milk  secretion  being  gradually  arrested  in 
the  affected  lobules.  Abscess  cavities  may  be  formed  from  acini 
as  well  as  from  interglandular  tissue.  Small  cavities  tend  to  co- 
alesce and  form  large  ones,  the  lining  wall  being  ragged  and 
irregular.  If  a  pus  cavity  communicates  with  an  open  duct,  the 
pus  may  escape  through  the  latter.  Sometimes  an  abscess  bursts 
through  the  skin,  pus  and  milk  flowing  through  the  opening. 
Sometimes  gangrene  occurs  in  these  cases.  Occasionally  general 
septicemia  or  pyemia  results.  Great  destruction  of  breast  tissue 
may  occur  as  the  result  of  extensive  infection. 


620  HYPERTROPHY  OF  SKIN  GLANDS   IN   THE   AXILLA. 

Submammary  inflammation  is  rare.  According  to  Billroth,  the 
infection  starts  in  the  deep-lying  glandular  tissue  and  spreads 
through  the  layer  of  dense  connective  tissue  at  the  base  of  the 
mamma  into  the  looser  tissue  underneath.  As  pus  accumulates 
the  breast  is  elevated,  and  can  usually  be  moved  as  though  it 
rested  on  a  water-bed. 

The  syniptouis  of  mastitis  are  those  of  inflammation  in  other 
parts,  varying  according  to  the  location,  extent,  and  nature  of  the 
infection,  etc.  Pain,  swelHng,  tenderness,  fever,  chills,  etc.,  are 
found.  When  pus  lies  near  the  surface,  it  may  be  detected  by 
palpation,  except  when  the  quantity  is  small.  When  deeply 
seated  it  may  easily  be  mistaken,  even  when  abundant.  The 
exploring-needle  may  require  to  be  used  in  its  detection. 

Trcatnioit. —  The  prophylactic  measures  to  be  adopted  are  those 
which  have  already  been  given  in  describing  the  hygiene  of  the 
breasts  during  pregnancy  and  the  nursing  period.  Milk  engorge- 
ment should  be  prevented  by  suitable  methods.  The  nipples  must 
be  kept  in  good  condition.  The  general  health  must  not  be 
allowed  to  decline. 

Wlien  mastitis  threatens,  the  most  satisfactor}'  means  of  check- 
ing the  process  is  to  apply  ice-bags  or  an  ice  coil  to  the  breast, 
protected  by  a  couple  of  layers  of  flannel,  the  patient  being  kept 
at  rest  in  bed.  Pain  is  likewise  greatly  diminished.  The  child 
should  be  taken  from  the  affected  breast,  and  the  milk  withdrawn 
by  a  breast-pump  or  by  massage.  Light,  dry  diet  should  be  ad- 
ministered, and  the  bowels  opened  with  salines.  Wlien  the  patient 
is  allowed  to  sit  up  the  breasts  should  be  supported,  enveloped  in 
cotton-wool,  and  a  binder  placed  over  them. 

When  pus  is  detected,  it  should  be  evacuated.  In  opening  su- 
perficial collections  local  anesthesia  may  often  suffice.  The  incision 
should  be  in  line  with  the  milk-ducts  and  should  be  free.  When 
there  are  several  cavities  it  may  be  advisable  to  break  down  the 
septa  between  them.  Sometimes  several  openings  are  necessary. 
The  areola  should  be  avoided  as  much  as  possible,  in  order  that 
healing  may  not  be  followed  by  abnormal  pigmentation.  Free 
drainage  is  necessary,  and  to  obtain  this  gauze  (chinosol  gauze  is 
satisfactory)  packing  or  drainage  tubes  may  be  used.  The  cavities 
may  be  irrigated  each  day  with  appropriate  antiseptic  solutions. 
A  submammary  abscess  should  be  opened  freely  at  the  most  de- 
pendent part  as  the  woman  lies  in  bed.  A  counteropening  may 
often  be  advisable,  in  order  that  the  cavity  may  be  well  irrigated 
and  drained. 

Hypertrophy  of  the  Skin  Glands  in  the  Axilla. — Occasionally 
a  skin-swelling  develops  in  or  near  the  axilla  on  one  or  both  sides 
three  or  four  days  after  labor ;  in  some  cases  more  than  one  may 
be  noticed  on  the  same  side.  Champneys  found  the  condition  37 
times  in  377  cases,  and  states  that  it  may  occur  rarely  in  preg- 


INJURIES    TO    THE   HEAD   DURING   LABOR. 


621 


nancy.  The  swelling  is  due  to  hypertrophy  of  sweat  glands,  which 
in  this  neighborhood  are  normally  longer  and  larger  than  those  in 
the  general  skin  surface.  Sometimes  a  little  secretion  may  be 
squeezed  from  the  swellings.  They  usually  subside  in  the  course 
of  a  i&w  days. 


CHAPTER    II. 
AFFECTIONS   OF  THE  NEWBORN  INFANT. 

Injuries  to  the  Head  during  I^abor. — Various  parts  of 
the  infant  may  be  injured  during  delivery,  the  head  being  most 
frequently  affected.  The  different  mouldings  of  the  latter,  marked 
by  changes  in  the  bones  and  by  the  development  of  a  swelling  in 
the  scalp  (caput  succedaneum),  have  already  been  described. 

Cephalhematoma  is  an  effusion  of  blood  between  the  peri- 
osteum and  the  outer  surface  of  the  bone  in  any  part  of  the  cranial 
vault.  It  occurs  rarely — about  once  in  200  or  250  labors,  according 
to  Ballantyne.  It  is  more  common  in  male  children  than  in  female  ; 
in  primiparse  than  in  multiparae.     It  is   usually  found  in  cases  of 


Fig.  262. — Longitudinal  section  through  a  cephalhematoma  :  a,  Dura  mater;  b,  cranium  ; 
c,  pericranium  ;   c' ,  c' ,  beginning  hyperostosis  ;  e,  scalp  (Davis). 

head  presentation,  though  it  may  be  present  in  others.  It  occurs 
generally  in  difficult  labors,  but  is  sometimes  found  when  delivery 
is  quick,  easy,  and  non-instrumental.  It  is  most  frequent  over  the 
parietal  region,  but  may  be  found  elsewhere.  The  cephalhema- 
toma may  appear  within  a  few  hours  or  days  after  labor.  Some- 
times more  than  one  swelling  may  be  found  on  the  head.  Fere 
has  found  fissures  in  the  parietal  bone  in  cases  of  cephalhema- 
toma, due  to  imperfect  development,  and  suggests  that  stretching 
of  them  during  labor  causes  rupture  of  small  vessels  running 
across  them,  leading  to  the  blood-accumulation.  The  effusion  is 
usually  limited  by  the  sutures  to  the  surface   of  the  bones.     The 


622  AFFECTIONS    OF   THE   NEWBORN  INFANT. 

elevated  periosteum  produces  bone  on  its  inner  surface,  especially 
around  the  base,  though  it  may  be  elsewhere.  The  effused  blood 
is  gradually  absorbed  within  a  couple  of  months.  Rarely  suppu- 
ration occurs.  On  palpation  the  swelling  is  at  first  uniformly 
tense ;  later  it  is  firmer  around  the  edges  than  it  is  in  the  center. 
When  a  ring  of  bone  is  found,  it  may  sometimes  be  mistaken  for 
a  perforation  in  the  skull.  There  is  no  pain  on  palpation  unless 
suppuration  occurs. 

The  condition  must  be  diagnosed  from  a  caput  succedaneum 
and  from  encephalocele.  Sometimes  blood-effusions  occur  be- 
tween the  periosteum  and  overlying  aponeurosis ;  these  are  not, 
however,  limited  by  sutures. 

Treatment. — The  swelling  should  be  protected  from  injury. 
Absorption  usually  occurs  spontaneously.  If  the  mass  increases 
in  size,  it  may  be  covered  by  sterile  wool  and  compressed  by  means 
of  adhesive  plaster.  If  signs  of  inflammation  develop,  the  mass 
should  be  incised  with  strict  asepsis  and  compresses  applied.  If 
symptoms  of  brain  irritation  should  develop,  incision  should  be 
carried  out  and  the  bone  examined  for  fracture,  trephining  being 
performed  if  necessary. 

Indentations  of  the  skull  may  be  furrow-shaped,  spoon- 
shaped,  and  cup-shaped,  the  first  two  being  most  frequent. 
Munro  Kerr  has  recentl)^  drawn  attention  to  the  spoon-shaped 
variety,  and  points  out  that  it  is  usually  found  after  labor  in  de- 
formed pelves,  especially  in  those  that  are  rickety.  It  is  usually 
found  in  cases  where  the  fetus  is  delivered  by  forceps  or  turning, 
though  it  may  occur  in  spontaneous  labor.  Indentations  are 
ordinarily  caused  by  the  promontory  of  the  sacrum,  though  they 
may  be  produced  by  the  anterior  pelvic  wall — c.  g.,  iliopectineal 
eminence  and  bony  growths  ;  also  by  an  ankylosed  coccyx  and  by 
tumors  of  the  soft  parts.  Veit  has  reported  a  case  in  which  the 
pelvis  was  normal,  the  indentation  being  produced  by  tetanic  con- 
tractions of  the  uterus,  due  to  ergot.  Contractions  of  the  pelvic 
floor  muscles,  prolapse  of  a  limb,  and  deviations  of  the  uterus 
have  also  been  mentioned  as  causes.  The  indentation  caused  by 
the  forceps  is  usually  furrow-shaped,  but,  according  to  Kerr,  the 
majority  of  indentations  found  in  forceps  cases  are  due  to  the 
pressure  of  the  head  against  some  bony  prominence. 

Sometimes  two  depressions  are  found  in  the  same  skull,  one 
being  usually  opposite  the  other.  The  results  of  the  indentations 
are  variable.  Sometimes  they  are  slight  and  disappear.  In  other 
cases  they  cause  death,  nervous  disturbances,  or  poor  health. 
Sometimes  death  may  be  prevented  if  the  indentation  be  at  once 
relieved. 

Various  methods  have  been  tried  to  effect  this.  Kerr  advo- 
cates compression  of  the  head,  and  states  that  he  has  several 
times  caused  the  indentation  to  be  bulged  out.     If  this   method 


INJURIES   OF  THE   MUSCLES. 


623 


fails,  surgical  interference  for  the  purpose  of  raising  the  depressed 
bone  should  be  tried. 

Fractures  of  Bones. — The  cranial  bones  may  be  fractured, 
the  parietals  being  most  frequently  affected.  The  injury  is  usually 
due  to  forceps,  though  it  may  occur  spontaneously,  especially  in 
birth  through  contracted  pelves.  Fracture  may  or  may  not  be 
followed  by  hemorrhage  external  or  internal  to  the  skull,  though 
either  or  both  of  these  may  be  present. 

The  brain  is  liable  to  be  injured,  but  often  escapes.  When  it 
is  lacerated,  the  lesion  may  be  serious.  Intracranial  hemorrhage 
may  also  cause  death.  When  there  are  no  symptoms  of  irritation 
or  compression  of  the  brain,  no  active  treatment  is  necessary. 
When  there  are  pressure  symptoms,  incision  of  the  scalp  is  ad- 
visable, the  depressed  skull  being  elevated  or  trephined. 


Fig.  263. 


-Triangular  depressed  fracture  of  fetal  skull  in  temporal  region  (Tarnier  and 
Budin). 


Fractures  of  the  limbs  mostly  occur  during  delivery  after 
turning  or  in  breech  cases.  Separation  of  the  epiphysis  from  the 
shaft  is  more  common  than  fracture.  Dislocations  are  rare.  The 
clavicle  or  inferior  maxilla  may  be  broken  in  attempts  to  deliver 
the  after-coming  head.  Fractures  of  the  vertebrae  are  usually 
fatal.  In  treating  these  accidents  it  is  almost  impossible  to  apply 
splints  satisfactorily.  Indeed,  when  the  upper  limbs  are  injured, 
they  should  be  bandaged  to  the  thorax. 

Injuries  of  the  Muscles. — Hemorrhage  is  sometimes  pro- 
duced in  the  substance  of  the  sternocleidomastoid,  especially  in 
breech  deliveries.  It  leads  to  the  formation  of  a  firm  swelling  or 
hematoma,   generally   situated  near  the  anterior   border   of  the 


624 


AFFECTIONS   OF   THE   NEWBORN  INFANT 


muscle.  It  may  occur  within  a  week  of  birth,  but  may  not  be 
detected  until  a  later  period.  It  usually  disappears  in  the  course 
of  a  few  weeks.  It  may  be  followed  by  inflammatory  changes 
and  contraction  of  the  affected  muscle  and  torticollis.  When  it 
is  discovered,  massage  and  inunction  should  be  carried  out. 

Injuries  of  tlie  Nerves. — Peripheral  injuries  to  nerves  oc- 
casionally occur.  The  seventh  nerve  is  sometimes  affected  by  the 
pressure  of  forceps,  leading  to  the  peripheral  form  of  facial  paralysis. 
The  nerve  is  injured  where  it  leaves  the  stylomastoid  foramen,  or 
where  it  divides  in  front  of  the  ear.     Sometimes  facial  paralysis  is 


Fig.  264. — Left  facial  paralysis  following  delivery  by  forceps  (Budin). 

produced  by  pressure  against  some  bony  point  in  the  maternal 
pelvis  in  non-instrumental  deliveries.  This  affection  is  noticeable 
when  the  child  nurses  or  cries.  Usually  the  nerve  recovers  its 
function.  If  it  is  slow,  faradism  may  be  employed.  Permanent 
paralysis  is  rare.  Sometimes  the  brachial  plexus  or  arm  nerves 
are  injured  by  pressure  of  the  physician's  fingers,  instruments,  or 
fractured  bones,  especially  in  artificial  delivery  in  breech  cases. 
The  deltoid,  biceps,  brachialis  anticus,  and  supinator  longus  are 
most  frequently  aftected.  In  marked  cases  the  injury-  is  noticeable 
soon  after  birth  ;  in  slight  cases  not  for  one  or  more  weeks.  The 
affected  muscles  tend  to  atrophy.  Some  cases  recover  entirely  in 
a  few  weeks,  others  only  after  months  or  years ;  others  never 
recover.  In  treating  these  conditions  massage  and  electricity 
may  be  started  ten  or  twelve  weeks  after  birth. 


ASPHYXIA   NEONATORUM.  625 

Injuries  of  the  Brain. — The  brain  may  be  injured  in  labor 
by  depressed  portions  of  fractured  bone,  by  intracranial  hemor- 
rhage, or  by  both  of  these  combined.  Most  frequently  it  is  due 
to  the  rupture  of  a  blood-vessel.  Menmgeal  hemorrhages  are 
more  frequent  than  cerebral,  the  arachnoid  space  being  a  favorite 
site.  The  accident  is  frequently  caused  by  forceps,  but  may  occur 
spontaneously  in  deformed  pelves  or  in  conditions  in  which  the 
head  is  subjected  to  marked  pressure. 

Sometimes  brain  injury  is  the  starting-point  of  mental  or 
physical  weakness  that  may  last  through  life — c.  g.,  epilepsy  and 
nervous  diseases.  Hemorrhage  may  cause  paralysis,  from  which 
recovery  may  or  may  not  take  place.  It  may  lead  to  compres- 
sion and  the  child  be  born  asphyxiated  or  comatose.  Vomiting, 
convulsions,  twitching,  and  stupor  may  be  produced.  Sometimes 
death  rapidly  supervenes. 

Other  Injuries. — The  pleura  may  sometimes  be  injured  in 
difficult  extractions.  Small  hemorrhages  are  not  infrequent  in 
the  thoracic  and  abdominal  viscera.  Sometimes  they  hav^e  been 
ruptured.  The  face,  breech,  and  trunk  may  be  much  swollen  and 
discolored  when  these  parts  present. 

Asphyxia  Neonatorum. — This  condition,  also  termed  "still- 
birth," is  due  to  causes  that  act  while  the  fetus  is  still  within  the 
genital  canal,  as  well  as  to  those  that  may  be  operative  after  the 
child  is  born.  The  intra-uterine  causes  act  by  interfering  with 
the  normal  respiratory  process  carried  on  in  the  placenta,  with  the 
fetal  circulation,  or  with  the  brain  centers.  They  are  as  fol- 
lows :  Premature  detachment  of  the  normally  situated  placenta ; 
separation  of  placenta  praevia ;  compression  of  the  umbilical  cord 
or  placenta ;  compression  of  the  brain  by  the  birth  passage, 
forceps,  or  intracranial  hemorrhage ;  maternal  diseased  conditions 
— e.  g.,  extreme  anemia  ;  and  sudden  death  of  mother.  In  cases 
in  which  the  circulation  in  the  cord  is  interfered  with  or  the 
respiratory  changes  in  the  placenta  checked  or  diminished,  the 
medullary  pulmonary  respiratory  center  is  stimulated,  and  am- 
niotic fluid,  mucus,  blood,  or  meconium  may  be  drawn  into  the 
air-passages.  In  other  cases — /.  e.,  when  the  brain  is  compressed — 
no  respiratory  efforts  may  be  made. 

Extra-uterine  causes  are  unruptured  membranes  and  the  pres- 
ence of  maternal  discharges  in  the  mouth  and  nose.  Sometimes 
the  child  falls  or  is  placed  in  such  a  position  as  not  to  be  able  to 
inhale  the  air. 

Diagnosis. — When  the  fetus  is  asphyxiated,  its  pulse-rate  be- 
comes slower  and  spasms  of  the  body  are  induced  as  respiratory 
efforts  are  made.  As  the  asphyxia  becomes  more  intense  the 
pulse  accelerates  and  respiratory  efforts  cease.  When  the  fetus 
is  in  the  uterus,  these  changes  in  the  heart-beats  may  sometimes 
be  detected  on  auscultation. 

40 


626  AFJ^ECTIONS   OF   THE   NEWBORN  INFANT. 

After  birth  the  appearance  of  the  infant  varies  according  to 
the  degree  of  asphyxia.  When  not  too  far  advanced,  the  heart 
beats  slowly  and  strongly,  the  muscular  tonicity  is  not  altogether 
lost,  occasional  respiratoiy  efforts  may  be  made,  and  the  reflexes 
are  not  entirely  abolished.  The  skin  is  much  congested  and 
darkened,  the  blood  containing  much  CO^,  and  hence  this  condi- 
tion is  often  termed  asphyxia  livida.  In  a  more  advanced  stage 
the  COg-poisoning  is  more  serious.  TKe  heart  is  rapid  and  feeble, 
the  muscles  are  flabby,  the  reflexes  abolished,  and  respiratoiy 
efforts  are  rarely  made.  The  skin  is  very  pale,  and  the  descrip- 
tion of  asphyxia  pallida  is  given  to  this  stage.  In  this  condition 
the  outlook  is  very  unfavorable.  In  every  case  in  which  the  heart 
beats  efforts  should  be  made  to  restore  respiration.  It  may  be 
difficult  in  some  cases  to  determine  whether  the  fetus  is  dead.  If 
the  heart  has  ceased  to  be  felt  or  heard,  mouth-to-mouth  insuffla- 
tion of  air  may  cause  it  to  beat  if  the  capability  be  present,  but  not 
if  it  is  stillborn.  In  the  latter  condition  the  temperature  may  fall 
rapidly  lo  to  15  degrees  below  normal. 

Treatment. — Preventive  measures  in  labor  are  all  procedures 
calculated  to  prevent  the  complications  that  cause  asphyxia. 
When  the  child  is  born,  it  should  be  held  by  the  feet  while  its  mouth 
and  fauces  are  cleansed  by  a  finger  covered  with  gauze.  At  the 
same  time  the  skin  should  be  slapped  and  sprinkled  with  cold 
water.  If  it  does  not  yet  breathe,  it  should  be  plunged  into  a  dish 
of  hot  water  (100°  to  105°  F.)  for  a  few  seconds,  and  then  lifted 
out  while  cold  water  is  sprinkled  on  its  chest.  This  procedure 
should  be  repeated  several  times.  The  child  should  not  be  placed 
in  a  ba.sin  of  cold  water,  since  too  much  heat  may  be  abstracted 
from  its  body.  When  these  measures  fail,  artificial  respiration 
must  be  carried  out.  Several  of  these  are  employed.  They  may 
be  tried  as  long  as  the  child's  heart  beats.  While  they  are  being 
tried  the  child  must  be  kept  warm. 

1.  Schultze's  Method. — This  consists  in  grasping  the  infant  from 
behind,  so  that  the  forefingers  are  in  the  axillae,  the  thumbs  in 
front  of  the  shoulders,  and  the  hypothenar  eminences  on  each  side 
of  the  head.  The  lower  part  of  the  body  is  then  swung  forward, 
upward,  and  inward  toward  the  physician's  face,  so  that  marked 
flexion  is  produced  and  the  lungs  compressed.  The  child  is  then 
restored  to  its  original  position,  the  body  being  extended,  so  that 
the  pressure  is  removed  from  the  lungs,  which  are  thus  able  to 
expand.  This  movement  should  be  repeated  about  ten  times  a 
minute. 

This  method  should  not  be  used  when  the  child  is  feeble.  Ac- 
cidents may  occur — e.g.,  slipping  of  the  infant  from  the  grasp, 
fracture  of  the  bones  and  trachea,  rupture  of  the  viscera,  and  in- 
ternal hemorrhages. 

2.  Blasts  Method. — This  consists  in  placing  the  child  so  that  its 


A  SPII YXIA    NE  O  h'A  TOR  UM. 


627 


anterior  surface  rests  on  the  palm  of  one  hand,  its  head  away  from 
the  operator,  the  limbs  and  head  hanging  down.  The  child  is  then 
turned  or  rolled  so  that  its  back  lies  on  the  other  hand,  in  an  atti- 
tude of  extension,  the  head  and  limbs  hanging  down.  It  is  then 
changed  to  the  other  hand.  In  this  way  alternate  expansion  and 
relaxation  of  the  chest  are  obtained.  Pressure  with  the  fingers  aids 
expiration. 

3.  Byrd's  Method. — The  child  is  placed  on  its  back  on  the 
palms  of  the  physician's  hands.  Alternate  flexion  and  extension 
of  the  trunk  are  then  carried  out  by  the  movements  of  the  hands. 

4.  Sylvester  s  Method. — The  child  is   placed   on   its   back,  the 


Fig.  265. — Schultze's  method  of  artificial  respiration :  A,  Inspiration  ;  B,  expiration. 

shoulders  slightly  raised,  the  lower  limbs  fixed,  and  the  tongue 
pulled  out ;  the  elbows  are  alternately  drawn  up  by  the  side  of 
the  head  and  then  slowly  depressed  against  the  chest,  so  as  to 
produce  the  effect  of  inspiration  and  respiration. 

5.  Laborde  recommends  rhythmic  traction  on  the  tongue. 

6.  Intubation  of  the  larynx  is  recommended  by  many.  A  gum- 
elastic  catheter  (No.  6  to  No.  8)  may  be  passed  into  the  trachea, 
while  air  is  blown  every  ten  seconds  into  the  lungs  by  the  physi- 
cian and  expelled  by  pressure  on  the  chest.  Fluid  that  may  have 
entered  the  air-passages  may  be  sucked  out  through  the  tube. 


628 


AFFECTIONS   OF   THE   NEWBORN  INFANT. 


Direct  insufflation  is  recommended  by  some.  The  child  is  placed 
on  its  back,  the  head  being  extended  by  means  of  a  rolled  towel 
placed  under  the  neck.  The  nose,  mouth,  and  fauces  are  cleansed 
and  a  handkerchief  placed  over  the  child's  face.  Holding  its  nose 
with  the  fingers  of  one  hand,  and  pressing  over  the  abdomen  with 
the  other  hand  to  prevent  distention  of  the  stomach,  the  physician 
gently  forces  air  from  his  own  mouth  into  that  of  the  child.  The 
chest  is  then  compressed  to  expel  the  air,  and  the  process  is 
repeated. 

Champneys  points  out  that  the  objections  to  direct  insufflation 

are — [a)  The  danger  of  rupturing 
the  lungs;  (/;)  the  risk  of  inflating 
the  stomach  ;  and  ic)  the  danger 
of  tuberculous  infection.  This 
author  has  made  a  special  study 
of  the  methods  of  restoration  de- 
scribed, and  recommends  especially 
those  named  after  Schultze  and 
Sylvester.  He  regards  the  pro- 
cedures of  Marshall  Hall  and 
Howard  as  useless  in  children. 

In  bad  cases  you  &^-  of  strych- 
nin may  be  injected  hypodermi- 
cally,  along  with  ten  drops  of 
brandy  or  whisky.  A  rectal  in- 
jection of  hot  normal  saline  solu- 
tion (105°  F.)  may  also  be  used. 
After  the  restoration  of  respiration 
in  an  asphyxiated  child  it  should 
be  watched  with  the  greatest  care 
during  the  first  day  or  two.  It 
must  be  kept  warm ;  hot  saline 
rectal  injections  may  be  given ; 
strychnin  and  brandy  may  be  used 
if  the  heart  is  feeble.  Pneumonia 
or  bronchitis  may  sometimes  follow 
in  cases  in  which  fluids  have  been 
drawn  into  the  lungs. 

Sepsis    Neonatorum. — The 
fetus   may  be   infected  in  various 
ways   at  the  time   of  labor — i.  e., 
through  the  navel,  abrasions  of  the  skin,  eyes,  respiratory  tract, 
alimentary  canal,  genital  passage,  and  urethra.     A  variety  of  dis- 
eases may,  therefore,  be  found. 

Some  Diseases  of  the  Newborn  Infant. — Septic  Infection 
of  the  Umbilicus. — Infection  of  the  umbilicus  may  cause  general 
sepsis  with  little  or   no   change  at  the   navel,  though   usually  an 


Fig.  266. — Two  varieties  of  insufflators. 


SOAIE   DISEASES   OF   THE   NEWBORN  INFANT.  629 

ulcer  forms  in  the  latter  situation.  The  thrombi  in  the  umbilical 
vessels  tend  to  break  down  and  the  vessel-walls  may  be  infected. 
In  some  cases  there  may  be  considerable  local  redness  and  swell- 
ing, which  sometimes  leads  to  abscess  or  gangrene ;  erysipelas 
sometimes  develops.  The  infected  navel  should  be  treated  with 
antiseptic  applications,  and  measures  must  be  adopted  to  keep 
up  the  general  strength.  Granulation  tissue  may  form  fungous 
masses  after  the  cord  drops  off;  sometimes  they  develop  around 
the  remnant  of  the  omphalic  duct.  Bloody  serum  usually  oozes 
from  them.  They  may  be  removed  by  repeated  application  of 
silver  nitrate,  but  it  is  most  satisfactory  to  ligate  the  base  and 
cut  the  mass  away. 

Omphalorrhagia  Neonatorum. — Bleeding  from  the  cord  may 
take  place  as  a  result  of  insecure  ligation,  shrinkage  of  the  cord 
after  ligation,  and  tearing  of  the  cord  between  the  ligature  and  the 
abdomen.  It  may  also  occur  after  the  cord  drops  off  The 
vessels  become  obliterated  from  the  ligature  toward  the  fetus,  and 
when  the  cord  separates,  the  thrombi  may  be  dislodged.  In  some 
cases  the  coagulability  of  the  blood  may  be  at  fault  as  the  result 
of  a  hemophilic  tendency,  jaundice,  syphilis,  sepsis,  or  some  other 
condition.  The  mortality  is  very  high  in  such  cases  because  of 
the  difficulty  in  controlling  the  hemorrhage. 

In  bleeding  due  to  slipping  or  slackening  of  the  ligature  the 
cord  should  again  be  tied.  When  the  trouble  occurs  after  the 
cord  has  dropped  off,  gauze  soaked  in  a  sterile  solution  of  gelatin 
in  normal  saline  (2  to  5  per  cent.)  should  be  packed  over  the  navel 
and  fastened  with  adhesive  plaster,  being  renewed  every  few  hours. 
If  this  is  not  successful,  the  umbilicus  may  be  transfixed  with  two 
needles  placed  at  right  angles,  a  figure-of-8  ligature  being  firmly 
fastened  around  them ;  these  should  be  kept  in  position  for  a  few 
days,  being  covered  with  antiseptic  dressings. 

Umbilical  Hernia. — At  birth  there  may  be  a  projection  of  the 
abdominal  cavity  outward  at  the  attachment  of  the  cord,  and  when 
the  latter  drops  off,  it  may  form  a  hernial  protrusion.  A  binder 
should  be  worn  over  the  projection. 

Icterus. — This  is  frequently  found  in  the  newborn.  In  mild 
forms  the  jaundice  is  slight  and  may  affect  only  the  head  and  chest. 
It  is  stated  to  be  due  to  blood-changes  or  to  bile  carried  into  the 
circulation.  Probably  the  first  of  these  is  generally  the  cause.  It 
usually  appears  on  the  second  day.  In  more  marked  forms  the 
whole  body  is  stained  deep  yellow.  The  jaundice  appears  within 
or  after  the  first  twenty-four  hours.  The  urine  is  high-colored  and 
the  feces  often  clay-colored.  There  may  be  slight  gastro-intestinal 
disturbances.  The  discoloration  may  last  for  days  or  weeks,  but  usu- 
ally improves  under  calomel  administration.  The  marked  forms  are 
chiefly  found  in  feeble  premature  infants  and  in  those  born  after 
lesions  or  difficult  labors,  especially  if  they  have  been  asphyxiated. 


630  AFFECTIONS   OF   THE   NEWBORN  INFANT. 

Malignant  icterus  is  rare  and  is  usually  associated  with  mal- 
formations in  the  bile-passages — /.  c,  absence  or  obliteration  of 
various  parts ;  in  such  cases  the  liver  is  usually  enlarged  and 
cirrhosis  is  present.  The  spleen  also  enlarges,  and  the  whole  ab- 
domen appears  abnormally  increased  in  size.  Hemorrhage  may 
take  place  at  the  navel,  nose,  mouth,  or  internally.  Death  takes 
place  usually  in  these  cases  within  a  {q.\\  weeks  or  months. 

Severe  jaundice  may  also  be  due  to  catarrh  of  the  bile-ducts ; 
also  to  inflammatory  changes  in  the  liver,  usually  caused  by  syphilis. 
It  is  also  caused  by  septic  infection. 

Melaena  neonatorum,  or  hemorrhage  in  the  stomach  or  in- 
testine, is  a  rare  occurrence.  It  is  generally  found  within  a  few- 
hours  of  labor.  The  cause  is  often  obscure,  and  may  be  due  to 
ulceration,  intussusception,  hemophilia,  or  ma}'  occur  in  jaundice. 
The  infant  may  vomit,  or  pass  from  the  rectum  red  or  black 
blood.     Death  often  results. 

The  condition  must  be  distinguished  from  that  in  which  blood 
is  swallowed — /.  c,  from  harelip,  cleft  palate,  nose  or  lungs,  or 
mother's  nipple. 

Hemoglobinuria. — This  is  a  rare  condition,  usually  occurring 
as  an  epidemic  in  maternity  hospitals,  and  developing  within 
two  or  three  days  of  birth.  The  infant  becomes  bronzed,  the 
soles  and  palms  being  violet-colored.  The  urine  and  feces  are 
darkly  pigmented.  The  pulse  is  rapid  ;  convulsions  and  squinting 
are  usually  present.  Fever  is  absent.  On  postmortem  examina- 
tion hemorrhages  are  found  in  many  situations.  The  disease  is 
probably  due  to  micro-organisms,  which  have  been  found  in  large 
numbers  in  the  blood  and  kidneys.  The  red  blood-corpuscles 
rapidly  diminish. 

Buhl's  disease  is  a  somewhat  similar  condition  ;  in  addition 
to  the  hemorrhages,  however,  there  is  marked  fatty  degeneration 
in  various  internal  organs.  Bleeding  from  the  navel  may  take 
place. 

Tetanus  is  rare ;  it  is  due  to  the  entrance  of  the  tetanus 
bacillus  through  the  navel.  The  symptoms  usually  begin  within 
ten  days  of  birth  and  the  disease  is  usually  fatal. 

Ophthalmia. — Conjunctivitis  may  sometimes  be  caused  by 
strong  antiseptic  lotions  that  enter  the  eyes  at  the  time  of  delivery. 
Generally  the  disease  is  due  to  infection  by  the  gonococcus  or 
septic  organisms.  If  these  are  introduced  at  birth,  the  symptoms 
appear  on  the  second  or  third  day.  When  they  develop  later,  the 
eyes  have  probably  been  infected  by  contact  with  infected  fingers, 
water,  or  cloths.  The  ocular  and  palpebral  conjunctivae  are  in- 
volved, and  there  is  an  abundant  purulent  discharge.  The  tissues 
are  much  swollen,  so  that  the  eyelids  may  scarcely  be  opened. 
There  are  photophobia,  tenderness  in  the  eyes,  and  fever.  Unless 
the  disease  is  checked  it  destroys  the  eye,  the  cornea  becoming 


SOME   DISEASES   OF   THE   NEWBORN  LKEANT.  63  I 

ulcerated.  If  it  begins  in  one  eye,  the  other  becomes  infected 
unless  well  protected. 

Treatment. — Prophylactic. — At  birth  the  eyes  should  be  washed 
out  with  normal  saline  solution.  Then  2  drops  of  10  per  cent, 
solution  of  protargol  or  of  a  2  per  cent,  solution  of  silver  nitrate 
should  be  placed  in  the  eyes.  They  should  then  be  washed  out 
with  normal  saline  solution. 

Ctirativc. — The  eyes  should  be  washed  out  every  hour,  day 
and  night,  with  saturated  boric  solution,  and  cold  compresses 
should  be  constantly  applied.  Two  or  three  times  a  day,  accord- 
ing to  the  intensity  of  the  affection,  the  protargol  or  silver  nitrate 
solution  should  be  dropped  in  the  eyes  and  washed  out  with 
normal  saline.  If  possible,  the  child  should  be  placed  in  charge 
of  an  oculist. 

Skin  Diseases. — Keratolysis — dermatitis  exfoliativa  or  Ritter's 
disease — is  sometimes  found.  It  consists  in  marked  exfoliation  of 
the  cuticle.  There  may  be  a  preceding  diyness,  followed  by 
erythema  and  exudation.  After  the  exfoliation  there  may  be 
eczema,  boils,  and  abscesses.  Constitutional  disturbances  may  be 
present. 

Pemphigus  sometimes  develops  in  the  newborn  child. 

Sclerema  is  a  rare  condition,  consisting  in  induration  of  the 
subcutaneous  tissue,  accompanied  by  a  lowering  of  body  tem- 
perature. 


CHAPTER    III. 

PUERPERAL  INFECTION. 

Puerperal  infection  is  a  term  applied  to  the  various  morbid 
processes,  pelvic  and  general,  that  are  manifested  in  lying-in 
women  as  a  result  of  the  action  of  micro-organisms  ;  they  are 
identical  in  character  with  the  various  forms  of  infection  that  may 
complicate  surgical  operations  or  wounds  of  the  body.  The  true 
nature  of  this  disease  has  only  recently  been  established,  and  the 
designation  here  employed  is  not  yet  universally  adopted,  a  much 
older  expression,  "puerperal  fever,"  introduced  by  Willis  in  1676, 
being  widely  used.  The  latter  term  should  be  discarded,  for 
while  it  emphasizes  a  prominent  clinical  feature,  the  former  indi- 
cates the  essential  etiologic  factor  in  the  disease — microbial  infec- 
tion;  and  the  employment  of  this  term  by  the  medical  profession 
may  serve  as  a  valuable  means  of  self-education. 

That  puerperal  infection  has  been  known  throughout  many 
ages  is  evident  from  references  to  it  in  works  of  writers  as  early 
as   Hippocrates.     Many  theories  ha'^e  been  advanced  to  explain 


632  PUERPERAL   INFECTION. 

its  occurrence.  At  various  periods  it  has  been  held  that  the  con- 
dition arose  from  decomposition  of  placental  remains  or  of  the 
lochial  discharge,  poisonous  matter  being  absorbed  into  the  sys- 
tem. Frequently  it  has  been  considered  as  a  special  mysterious 
scourge  sent  by  Providence.  It  has  often  been  attributed  to 
atmospheric,  climatic,  or  geographic  conditions. 

In  1 79 1  Dr.  White,  a  surgeon  in  Manchester,  England,  pubhshed  a 
work  in  which  he  stated  that  puerperal  fever  was  due  to  the  absorption  of 
putrid  material  by  the  lymph-  and  blood-vessels  of  the  uterus.  He  noticed 
the  resemblance  between  puerperal  fever  and  the  disturbances  associated 
with  putrid  changes  in  other  parts  of  the  body.  He  pointed  out  that 
puerperal  fever  almost  always  developed  after,  and  not  before,  delivery, 
and  observed  that  surgical  openings  often  became  putrid.  In  his  treatment 
of  lying-in  women  he  tried  to  prevent  putrefaction  and  to  eradicate  it  when 
it  developed.  He  recommended  ventilation,  cleanliness,  drainage,  and  a 
daily  change  of  clean  linen,  and  urged  that  foul,  damp,  or  overheated  air 
should  be  avoided.  In  order  to  prevent  accumulation  of  the  lochial  dis- 
charge in  the  vagina  he  advised  patients  to  sit  up  in  bed  or  out  of  bed,  to 
lessen  the  chance  of  putrefactive  changes.  He  injected  antiseptics  into  the 
uterus  in  cases  of  puerperal  fever,  and  observed  that  the  latter  was  assuaged 
and  in  many  cases  wholly  extinguished.  White's  views  and  practice  failed 
to  influence  the  profession  of  his  time  and  were  rapidly  forgotten.  In  1839 
Ferguson  associated  an  outbreak  in  the  Westminster  Lymg-in  Hospital 
with  an  unclosed  sewer  in  the  neighborhood.  By  many  puerperal  infection 
has  been  termed  an  inflammatory  disease.  Plater,  in  the  seventeenth  cen- 
tury, being  the  first  to  emphasize  the  prominence  of  inflammation  in  the 
uterus.  About  the  middle  of  the  eighteenth  century  Puzos  advanced  the 
view  that  the  disease  was  caused  by  a  milk  metastasis.  Ritger,  in  the  early 
part  of  the  nineteenth  century,  considered  that  there  was  a  metastasis  to 
the  peritoneum  and  other  parts,  not  of  milk,  but  of  the  blood  destined 
to  form  that  secretion — a  view  widely  held  in  Germany  at  the  time.  About 
the  same  period  Locock  and  Ingleby  insisted  upon  the  nervous  nature  of 
the  affection.  Ferguson  held  that  it  resulted  from  a  vitiation  of  the  fluids, 
and  that  all  the  varieties  of  puerperal  fever  depended  on  this  one  cause. 
In  1837  Eisenmann  stated  that  he  considered  puerperal  fever  to  be  identical 
with  surgical  septicemia. 

In  1843  Oliver  Wendell  Holmes  published  an  important  paper  in  which 
he  called  attention  to  ' '  the  contagiousness  of  puerperal  fever "  ;  it  had 
very  little  influence,  and  served  only  to  excite  the  fiercest  criticism  among 
the  leading  obstetricians  of  the  time.  Samuel  Kneeland,  in  1846,  stated 
that  puerperal  fever  could  be  produced  by  the  inoculation  of  a  woman  with 
fluid  from  a  sick  woman  or  from  the  body  of  one  who  had  died  after  labor, 
as  well  as  from  air  vitiated  by  sick  persons,  especially  when  several  women 
were  together  in  a  hospital  ward,  ill  with  puerperal  fever.  He  stated  that 
infection  could  be  carried  by  the  physician,  clothes,  and  everything  that 
had  been  in  contact  with  a  woman  already  infected. 

In  1846  Semmelweiss,  an  assistant  in  the  Vienna  Lying-in  Hospital, 
began  his  memorable  observations  on  the  cases  of  puerperal  infection  oc- 
curring in  that  institution.  In  studying  the  history  of  the  institution  he 
found  that  from  1784  to  1822  the  obstetricians  performed  no  postmortem 
examinations,  and  that  the  average  mortahty  during  that  period  was  1.25 
per  cent.  From  1825  to  1833  postmortem  examinations  were  made,  the 
mortahty  increasing  to  5.3  per  cent.      In  1839  the  institution  was   divided 


MICROBIAL    FACTORS  IN  PUERPERAL    INFECTION.      633 

into  two  parts,  one  for  students,  the  other  for  midwives.  In  the  latter  the 
mortality  fell  to  2.6  per  cent.,  whereas  in  the  former  it  rose  to  9.5  per  cent., 
remaining  at  this  level  for  five  years,  excepting  in  1841-43,  when  for  a 
period  of  twenty  months  it  averaged  16  per  cent.,  at  one  time  being  as  high 
as  31.3  per  cent. 

One  of  his  friends,  in  making  an  autopsy  on  a  case  of  puerperal  fever, 
contracted  blood-poisoning  and  died  after  a  short  severe  illness.  Semmel- 
weiss  noted  that  the  postmortem  conditions  were  similar  to  those  often  found 
in  women  who  had  clied  of  puerperal  infection,  multiple  abscesses  and  sup- 
purative phlebitis  being  present.  He  concluded  that  the  lying-in  women 
were  inoculated  by  the  fingers  of  students  who  worked  in  the  autopsy-  and 
dissecting-rooms,  and  he  believed  the  infective  material  to  be  animal  mat- 
ter. Thereupon  he  ordered  the  students  in  attendance  upon  the  women  to 
refrain  from  making  autopsies  and  to  wash  their  hands  in  a  solution  of 
chlorid  of  lime.  Immediately  the  mortality  from  puerperal  infection  fell  to 
3.05  per  cent.  Subsetjuently  he  stated  that  the  infective  material  was  not 
only  cadaveric  material,  but  any  animal  tissues  in  a  state  of  putrefaction, 
and  also  the  lochial  discharge  of  women  already  diseased.  He  insisted 
that  possible  carriers  of  infection — i.  e.,  hands,  clothes,  and  instruments — 
should  be  cleansed.  The  mortality  soon  fell  to  1.27  per  cent.  Owing  to 
the  jealousy  of  his  colleagues,  Semmelweiss  was  forced  to  leave  Vienna, 
and  his  ideas  found  little  acceptance  anywhere.  In  Buda-Pesth  the  mor- 
tality in  the  Rochus  Hospital  under  his  supervision  averaged  0.85  per  cent. 

Sir  James  Y.  Simpson  made  similar  observations  about  the  same  time 
in  Edinburgh,  and  for  several  years  had  used  cyanid  of  potassium  as  a 
handwash  before  attending  women  in  labor.  In  185  i  he  strongly  insisted 
upon  the  origin  of  puerperal  fever  from  infecting  material  directly  trans- 
ferred from  women  ill  of  the  disease,  from  dead  bodies,  and  other  sources, 
and  pointed  out  the  resemblance  between  puerperal  and  surgical  fevers. 
Though  he  differed  with  Semmelweiss  in  some  minor  points,  he  supported 
his  main  conclusions.  Tarnier,  in  1857,  and  Trousseau,  in  1858,  also 
recognized  the  likeness  between  puerperal  and  surgical  infections.  For 
years,  however,  these  views  made  little  progress,  and  the  death-rate  among 
women  in  Europe  and  America,  due  to  puerperal  infection,  remained  high, 
especially  in  maternity  hospitals.  As  late  as  1872  Churchill's  well-known 
text-book  stated  that  puerperal  fever  was  due  to  mental  emotion,  putrefac- 
tion of  retained  placenta,  gastro-enteric  irritation,  the  state  of  the  atmo- 
sphere, epidemic  influences,  and  contagion.  Gradually,  however,  the  con- 
tagious nature  of  the  disease  became  generally  admitted.  Rokitansky,  in 
1864,  found  germs  in  the  lochia,  and  by  injecting  the  latter  into  animals, 
produced  abscesses.  In  1867  Tarnier  isolated  the  infected  cases  in  his 
maternity  and  the  mortality  was  immediately  reduced  from  about  10  per 
cent,  to  2.32  per  cent. 

Pasteur's  magnificent  studies  of  micro-organisms,  and  Lister's  work  in 
demonstrating  that  surgical  infection  was  due  to  their  growth  in  human 
tissues,  very  soon  led  to  the  investigation  of  puerperal  infection,  and  in 
the  last  thirty  years  great  progress  has  been  made  in  the  study  of  the 
various  microbes  which  are  capable  of  producing  the  disease,  their  modes 
of  entrance  into  the  body,  and  the  means  of  protecting  the  lying-in  woman 
from  their  action. 

Microbial  Factors  in  Puerperal  Infection. — Strepto= 
coccus  Pyogenes — Thi.s  organism  wa.s  first  discovered  in  the 
lochia  of  women  with  puerperal  sepsis  by  Mayerhofer,  in  1865. 
In    1869   Coze  and   Fcltz  found  it  in  the  blood  of  such  cases  in 


634  .  PUERPERAL    INFECTION. 

short  and  long  chains.  Pasteur  first  cultiv^ated  it  in  1879,  and  his 
pupil,  Doleris,  in  1880,  proved  its  fi-equency  as  an  infecting  agent. 
Many  other  workers  have  added  to  our  knowledge  of  this  organ- 
ism. While  it  is  found  in  different  forms,  these  have  not  been 
classified  into  distinct  species,  and  we  are  not  able  to  associate 
particular  forms  with  different  clinical  manifestations.  It  has  been 
shown  that  streptococcus  may  be  made  to  grow  in  short  chains 
or  long  chains  according  to  the  condition  of  growth.  Great 
variations  are  found  in  the  virulence  of  the  organism  according 
to  the  conditions  of  its  development.  Thus,  Marmorek  has  shown 
that  the  same  species  may  cause  at  one  time  merely  a  slight  tem- 
porary erythema,  at  another  a  local  suppuration,  at  another  a 
spreading  erysipelas,  at  another  a  general  septicemia.  Its  viru- 
lence rapidly  diminishes  in  cultures,  and  tends  to  increase  in 
passing  from  one  human  being  or  animal  to  another.  Of  great 
importance  was  the  demonstration  that  eiysipelas  is  caused  by 
the  streptococcus  of  septicemia.  Widal  and  Besanqon  have 
shown  that  in  the  mouth  a  non-pathogenic  form  of  strepto- 
coccus is  often  found  which  may  be  made  virulent  by  passing 
it  through  a  series  of  animals  or  by  inoculating  it  along  with  the 
colon  bacillus. 

In  the  puerperal  w^oman  streptococcus  may  cause  a  great 
variety  of  local  and  general  septic  processes.  In  its  parasitic  action 
it  does  not  lead  to  foul-smelling  lochia ;  when  this  feature  is 
present  in  a  streptococcic  infection,  it  is  usually  due  to  the  action 
of  associated  saprophytes.  It  is,  however,  possible  that  occa- 
sionally the  organism  may  be  so  modified  as  to  act  only  as  a 
saprophyte. 

The  streptococcus  must  be  regarded  as  a  very  frequent  cause 
of  puerperal  infection  and  the  most  frequent  cause  of  fatal  cases. 
Czerniewski  found  it  in  49  out  of  91  cases;  Wldal,  in  14  out  of 
16  cases  ;  Kronig,  in  56  out  of  296  cases  ;  while  Bumm  found  it 
in  ever}'  one  of  17  cases.  In  a  small  percentage  of  cases  it  is 
mixed  with  staphylococci  or  other  organisms.  It  is  capable  of 
penetrating  the  uterine  wall  to  a  greater  extent  than  other  in- 
fecting germs. 

In  some  cases  of  streptococcic  infection  the  micro-organism 
may  have  so  little  virulence  as  to  cause  little  or  no  febrile  disturb- 
ance. It  is  undoubtedly  most  virulent  when  it  attacks  the  tissues 
as  a  parasite,  having  passed  through  no  recent  saprophytic  stage. 

Staphylococcus. — While  in  puerperal  women  the  breasts  are 
most  frequently  the  site  of  infection  by  staphylococci,  the  genitalia 
may  also  be  attacked  and  both  local  and  distant  morbid  processes 
may  be  induced.  In  almost  all  cases  investigated  Staphylococcus 
aureus  has  been  found,  the  other  varieties  being  unimportant  as 
causal  factors.  The  first  demonstration  of  their  causal  relation- 
ship to   puerperal   sepsis  was   made   by  Brieger,  in    1888.     The 


MICROBIAL    FACTORS  IN  PUERPERAL    INFECTION.      635 

results  of  infection  vary  greatly  ;  they  may  be  mild  or  severe  and 
may  end  in  death. 

Qonococcus. — The  gonococcus  plays  an  important  role  in 
puerperal  infection,  producing  mainly  local  pelvic  changes — i.  e., 
endometritis,  salpingitis,  ovaritis,  perimetritis,  etc.  It  is  rare  that 
distant  affections  are  produced — e.  g.,  endocarditis  and  arthritis. 
Kronig,  in  1895,  reported  that  he  found  the  gonococcus  in  50  out 
of  179  cases  in  which  febrile  symptoms  occurred  in  the  puer- 
perium.  Occasionally  the  organism  may  be  found  in  the  lochia 
without  any  febrile  disturbances.  In  almost  all  cases  the  results 
of  infection  do  not  lead  to  death  ;  sometimes,  however,  there  is  a 
fatal  termination.  It  is  of  importance  to  note  that  the  condition 
of  the  maternal  tissues  after  labor  is  particularly  favorable  to 
the  renewal  of  activity  on  the  part  of  gonococci  which  have  been 
lying  latent  in  the  female  genitalia,  whether  derived  from  an  old 
infection  in  the  woman  or  man.  It  not  infrequently  happens  that 
a  woman  is  infected  by  the  discharge  from  a  husband  affected 
with  old,  uncured  gonorrhea,  as  a  result  of  the  changes  in  her 
tissues  caused  by  pregnancy  and  labor,  whereas  previously, 
though  subjected  to  the  same  risk,  the  tissues  were  able  to  resist 
the  action  of  the  gonococcus. 

Colon  Bacillus. — Von  Franque,  in  1893,  reported  this  organ- 
ism as  a  cause  of  puerperal  infection,  and  it  has  also  been  found 
by  Widal,  Kronig,  Marmorek,  Williams,  and  many  others.  It  is 
indeed  surprising  that  it  is  not  a  more  frequent  cause,  when  the 
nearness  of  the  rectum  to  the  genital  tract  and  its  abundance  in 
the  feces  are  remembered.  Vignal  calculates  that  i  decigram  of 
feces  contains  20,000,000  of  colon  bacilli;  Gilbert  and  Dominici 
state  that  12,000,000,000  to  15,000,000,000  are  passed  in  the 
feces  each  day.  This  organism  generally  remains  in  the  super- 
ficial layer  of  the  endometrium,  and  is  most  likely  to  cause  infec- 
tion when  portions  of  the  placenta  and  membranes  are  left  in  the 
uterus.  In  its  growth  it  causes  fetor  in  the  lochia,  and  also  may 
produce  gas  that  may  distend  the  uterus.  This  was  first  stated 
by  Gebbard,  in  1896.  Schnell  afterward  grew  the  organism  in 
liquor  amnii,  but  was  unable  to  produce  gas.  It  is  held  by  some 
that  this  feature  is  due  to  the  accompanying  growth  of  certain 
saprophytes.  When  there  is  a  mixed  infection  of  colon  bacillus 
and  streptococcus  or  staphylococcus,  the  virulence  of  the  organism 
is  greater.  Urinary  infection  in  the  puerperium  is  most  frequently 
due  to  the  colon  bacillus. 

Bacillus  Dlphtheriae. — True  diphtheric  infection  of  the  genitalia 
is  very  rare,  yet  it  may  sometimes  be  found.  Nisot,  Bumm,  Wil- 
liams, and  others  have  found  the  Klebs-Loffler  bacillus,  and 
affected  patients  have  been  cured  by  antidiphtheric  serum.  Most 
cases  of  so-called  "  diphtheric  infection  "  are  those  in  which  other 
organisms — c.  g.,  streptococci — are  the  infecting  agents. 


636  PUERPERAL   INFECTION. 

Pneumococcus. — Rarely  this  organism  is  found  in  the  lochia 
of  infected  women,  alone  or  combined  with  other  organisms.  The 
genitalia  may  be  primarily  attacked,  or  secondarily  following  sys- 
temic infection.  The  fetus  may  be  infected  during  labor  and  de- 
velop pneumonia  soon  afterward. 

Tetanus  Bacillus. — Rarely  a  patient  may  be  infected  with  this 
organism  after  labor,  manifestations  appearing  usually  within  two 
weeks  ;  according  to  Rubeska,  from  the  sixth  to  the  eleventh  day. 
It  has  been  held  by  some  that  the  infection  always  follows  changes 
in  the  genital  tract  caused  by  other  organisms — c.  g.,  streptococci — 
but  this  statement  is  denied  by  others.  The  disease  usually  runs 
a  rapid  course  and  is  fatal  in  the  great  majority  of  cases.  Some- 
times its  duration  is  protracted  and  irregular.  The  temperature  is 
usually  elevated,  marked  variations  being  found. 

Bacillus  Aerogenes  Capsulatus. — Several  cases  have  been  de- 
scribed in  which  this  bacillus  of  Welch  has  been  associated  with 
puerperal  infection.  It  grows  chiefly  in  dead  organic  matter  and 
produces  gas,  which  rapidly  accumulates  in  the  tissues.  Dobbin 
found  it  in  the  fetus  and  placenta  of  a  woman  in  whom  the  former 
was  dead  and  retained  in  the  uterus  several  days  as  the  result  of  a 
pelvic  contraction.  The  lochia,  fetus,  and  placenta  were  fetid  and 
contained  gas  ;  the  body  of  the  woman  became  rapidly  distended 
^vith  gas  after  her  death.  The  organism  probably  forms  very 
virulent  toxins. 

Other  Organisms. — A  few  cases  of  infection  with  the  typhoid 
bacillus,  Proteus  vulgaris,  and  anthrax  have  been  reported.  It  is 
possible  that  certain  bacilli  which  are  as  yet  unclassified  may  be 
able  to  induce  true  septic  infection  in  the  puerperium.  The 
Bacillus  septicus,  described  by  Pasteur  and  Doleris,  was  in  all 
probability  only  one  of  many  saprophytic  bacteria  capable  of  de- 
veloping on  dead  or  dying  tissue  in  the  genital  tract  and  affecting 
the  woman  by  the  toxins  elaborated. 

Sapremia. — In  many  cases  puerperal  infection  is  simply  due 
to  saprophytic  organisms  which  enter  the  genital  tract  and  attack 
dead  or  dying  fetal  and  maternal  tissues,  the  woman  being  affected 
by  the  absorption  of  the  toxic  products  of  their  g;rowth.  In  the 
great  majority  of  cases  these  organisms  are  anaerobic,  many  of 
them  producing  gas  and  fetor.  Only  a  few  of  these  have  been 
isolated.  They  may  also  frequently  be  associated  with  the  various 
pathogenic  organisms  above  described — a  fact  that  must  always 
be  remembered  in  making  a  diagnosis.  Whether  some  of  these 
saprophytes  may  also  become  parasitic  and  directly  infect  the 
living  organism  is  somewhat  uncertain. 

From  recent  investigations  it  seems  likely  that  these  anaerobes, 
which  can  only  grow  in  the  absence  of  oxygen,  may  invade  the 
uterine  wall  and  other  tissues,  producing  a  real  septic  infection. 
(It  is  believed  by  some  that  this   may  also   occur  when  they  are 


SOURCES   OF  INFECTION.  637 

mixed  with  the  colon  bacillus.  The  latter  grows  with  or  without 
oxygen,  and  if  it  absorbs  oxygen,  which  may  be  present  in  the 
genital  canal,  it  may  lead  to  increased  virulence  of  the  sapro- 
phytes and  enable  them  even  to  penetrate  the  uterine  wall.)  These 
anaerobes  have  been  found  in  parametric  abscesses  and  in  puru- 
lent peritonitis.  They  cannot  invade  vessels  containing  circulating 
blood  on  account  of  the  oxygen  in  the  blood,  but  they  may  enter 
old  thrombi,  lymphatics,  or  serous  cavities.  Kronig  thinks  that 
such  invasions  are  not  so  rare  as  might  be  supposed  ;  indeed,  he 
says  that  pure  sapremia  without  some  invasion  of  the  tissues 
is  the  exception  rather  than  the  rule.  The  disturbances  pro- 
duced are  generally  much  milder  than  those  due  to  the  pyogenic 
organisms. 

It  is  probable  that  pathogenic  organisms  may  assume  a  sapro- 
phytic role  in  the  genital  tract.  In  some  cases  in  which  sapremic 
features  are  prominent,  streptococci  alone  may  be  found  and  cul- 
tivated. It  has  been  stated  that  these  organisms  may  lose  their 
virulence  and  live  a  saprophytic  existence  in  the  vagina.  While 
it  is  possible  that  putrefactive  changes  may  be  due  to  these  modi- 
fied organisms,  it  must  always  be  remembered  that  they  may  be 
due  to  anaerobes  which  have  escaped  detection  and  cultivation. 
Kronig,  in  179  cases  of  puerperal  infection,  reported  50  as  sapremic, 
in  43  of  which  he  found  organisms  which  would  not  grow  on  the 
ordinary  culture  media,  32  being  anaerobic. 

Mixed  Infection. — The  occasional  combination  of  different 
pathogenic  organisms  in  producing  infection  has  already  been 
noted.  Such  cases  are  apt  to  be  more  virulent  than  when  single 
infection  is  present.  In  treating  an  infected  woman  it  is  necessary 
that  a  strict  technic  be  observed,  in  order  that  other  organisms  be 
not  introduced.  The  association  of  pathogenic  and  saprophytic 
organisms  has  also  been  noted. 

Sources  of  Infection. — Hetero=infection. — In  the  great  ma- 
jority of  cases  infecting  organisms  are  introduced  by  the  hands  or 
instruments  of  obstetricians,  nurses,  and  midwives  who  are  surgi- 
cally dirty  and  careless  in  their  technic.  The  direct  transmission 
of  infection  by  physicians  from  septic  wounds,  puerperal  septice- 
mia, erysipelas,  etc.,  has  been,  unfortunately,  so  often  demonstrated 
that  it  is  not  necessary  to  dwell  on  the  fact.  Infection  from  sores 
on  the  hands  of  physician  or  nurse  has  also  been  clearly  estab- 
lished, as  well  as  from  hands  not  diseased  but  imperfectly  cleansed. 
In  some  cases  the  genital  tract  may  be  infected  by  clothing,  pads, 
rags,  etc.,  or  by  water  used  in  cleansing  or  douching  the  genitals. 
Sometimes  the  woman  herself  maybe  responsible,  introducing  her 
dirty  fingers  into  the  vagina.  Coitus  shortly  before  or  after  labor 
is  sometimes  the  means  of  introducing  infecting  organisms.  Refer- 
ence has  already  been  made  to  this  means  in  cases  of  latent 
gonorrhea  in  the  husband.     Infection  is  believed  by  some  to  be 


638  PUERPERAL    INFECTION. 

frequently  carried  by  the  air,  and  many  cases  have  been  described 
in  which  a  bad  water-closet,  a  leaky  sewer,  or  a  dead  animal  has 
produced  the  infecting  agents  that  have  been  transferred  to  the 
patient  by  the  air.  It  cannot  be  denied  that  puerperal  infection 
is  possible  in  this  way,  but  it  must  be  regarded  as  a  rare  occur- 
rence. If  the  influence  of  dirty  fingers  and  instruments  could  be 
eliminated  from  the  lying-in  chamber,  the  condition  of  the  atmo- 
sphere need  not  cause  much  anxiety. 

Autoinfection. — Semmelweiss  first  used  the  term  "  autoinfec- 
tion,"  meaning  thereby  an  infection  by  decomposed  animal  mate- 
rial produced  within  the  patient  herself  When  the  germ  theory 
of  disease  became  established  and  antiseptic  methods  were  intro- 
duced into  obstetric  practice,  autogenetic  infection  was  scarcely 
considered  possible,  since  it  could  not  be  thought  that  micro- 
organisms originated  dc  novo  in  the  human  body. 

In  course  of  time  the  occurrence  of  puerperal  sepsis  in  occa- 
sional cases  in  which  a  strict  technic  was  believed  to  have  been 
employed  led  to  the  expression  of  belief  that  the  genital  canal  is 
normally  the  seat  of  pathogenic  micro-organisms,  which  may  be 
introduced  into  the  uterus  at  the  time  of  labor,  causing  infection. 
This  view  was  strongly  advocated  by  Kaltenbach  and  Ahlfeld. 
In  recent  years  many  bacteriologic  studies  of  the  vagina  have  been 
made  to  determine  the  truth  regarding  its  normal  contents  in 
pregnancy.  A  short  account  of  this  work  has  been  already  given. 
(Seep.  III.)  Regarding  the  cavity  of  the  uterus  in  pregnancy, 
there  is  general  agreement  that  it  is  normally  sterile.  Reports  as 
to  the  cervix  have  been  somewhat  at  variance,  but  the  most  care- 
ful studies  show  that  the  upper  part  of  its  canal,  at  least,  is  free 
from  organisms.  Regarding  the  lower  part  of  the  canal  and  the 
whole  vagina  there  has  been  much  dispute,  but  the  researches  of 
Kronig,  Menge,  Williams,  and  others  show  that  this  passage  is 
normally  sterile  as  regards  pathogenic  organisms,  and  that  these, 
if  introduced,  are  undoubtedly  destroyed  by  the  vaginal  secretion, 
with  the  exception  of  the  gonococcus.  Regarding  the  various 
anaerobes  found  in  the  vagina,  little  is  known. 

The  lochial  fluid  has  been  investigated  in  normal  non-febrile 
cases  by  different  observers.  Thus,  Doderlein  found  it  sterile  in 
26  cases  out  of  27;  Czerniewski,  in  57  cases,  found  it  sterile  in 
56;  Kronig,  in  63  cases,  found  organisms  in  13  cases — viz.. 
Streptococcus  pyogenes  in  3 ;  staphylococcus  in  2  ;  gonococcus 
in  4 ;  Bacillus  coli  communis  in  4,  and  various  anaerobic  organ- 
isms in  6  cases.  The  discrepancies  between  Kronig's  results  and 
those  of  the  other  observers  are  probably  explained  by  the  differ- 
ences in  the  methods  of  examination,  Kronig's  technic  being  more 
thorough.  In  regard  to  the  presence  of  pathogenic  organisms  in 
a  febrile  condition  it  is  to  be  stated  that  they  may  be  of  such 
slight  virulence  as  to  cause  little  disturbance.     It  is  also  possible 


CONDITIONS  FAVORING   INFECTION.  639 

that  the  germs  might  have  been  introduced  in  the  process  of  ob- 
taining the  lochial  fluid. 

At  the  present  time  it  must  be  held  that  autoinfection,  in  the 
sense  of  infection  by  organisms  having  a  normal  habitat  within 
the  genital  tract,  is  impossible.  The  term  is,  however,  loosely 
applied  by  many  to  include  cases  of  the  following  nature :  The 
uterine  mucosa  may  have  been  infected  with  the  gonococcus 
before  or  during  pregnancy,  and  the  organisms,  though  latent, 
may  show  renewed  activity  as  a  result  of  labor,  causing  signs 
and  symptoms  of  an  infection  which  is  almost  always  Hmited  to 
the  pelvis. 

In  some  cases  a  necrotic  carcinoma  or  sloughing  fibroid  in  the 
region  of  the  cervix,  an  old  abscess,  or  a  vesical  or  rectal  fistula 
may  give  rise  to  the  infection.  In  cases  of  pneumonia,  scarlatina, 
and  other  specific  diseases  the  infecting  organism  may  set  up  local 
changes  in  the  pelvis,  reaching  the  uterus  by  the  blood  or  air. 
Occasionally  a  puerperal  infection  may  develop  from  a  focus  ex- 
ternal to  the  uterus — e.g.,  salpingitis,  appendicitis,  parametritis,  etc. 
These  old  infected  areas  may  have  caused  symptoms  during  the 
pregnancy  or  may  have  been  in  a  quiescent  condition.  As  a  result 
of  the  changes  in  labor — stretching,  tearing,  bruising,  etc. — the 
tissues  become  more  favorable  to  the  growth  of  organisms,  so  that 
they  may  multiply  and  spread,  causing  fresh  infection.  Occasion- 
ally it  is  possible  that  injuries  in  the  region  of  the  iiitroitus  vagincB 
may  lead  to  an  infection  by  the  colon  bacillus.  Infection  in  the 
urinary  tract  may  be  the  cause  of  puerperal  sepsis  in  some  cases, 
the  colon  bacillus  being  frequently  the  active  organism.  Con- 
tamination probably  arises  from  urine  entering  the  vagina,  though 
it  may  possibly  enter  the  uterus  directly  through  the  wall  of  the 
bladder. 

The  term  "  autoinfection,"  in  the  strict  meaning  of  the  word, 
cannot  be  applied  to  such  cases  as  these ;  the  expression  "  sec- 
ondary infection  "  would  more  correctly  explain  their  nature.  In 
conclusion  it  must  be  urged  that  in  all  cases  in  which  the  ob- 
stetrician is  prone  to  take  refuge  in  autoinfection  as  an  explanation 
of  some  unhappy  case  of  puerperal  sepsis,  he  should  institute  a 
rigid  inquiry  as  to  the  details  of  the  technic  that  has  been  ob- 
served during  the  confinement. 

Conditions  Favoring  Infection. — General  poor  health  of 
the  woman,  fatigue  due  to  prolonged  labor,  loss  of  blood,  and  all 
debilitating  conditions  undoubtedly  render  the  tissues  less  able  to 
resist  the  invasion  of  micro-organisms.  The  relationship  between 
premature  rupture  of  the  membranes  and  puerperal  infection  has 
been  often  noted.  This  is  explained  by  some  on  the  ground  that 
the  liquor  amnii  which  escapes  and  remains  in  the  vagina  is  a 
good  culture  medium  for  micro-organisms.  Normally  during 
labor  the   liquor  amnii  and  fetus  are  free  from   micro-organisms. 


640  PUERPERAL   INFECTION. 

Kronig  and  Menge  have  shown  that  the  uterine  cavity  may  be 
invaded,  an  infective  process  being  set  up.  Putrefactive  organisms 
may  grow  in  the  Hquor  amnii,  their  toxins  being  absorbed.  These 
processes  may  cause  febrile  disturbances  during  labor.  These 
authors  have  also  shown  that  sometimes  pathogenic  and  sapro- 
phytic organisms  may  grow  in  the  liquor  amnii  at  this  time 
without  causing  any  disturbance  in  the  mother.  Probably  the 
fatigue  of  such  labors,  which  are  usually  tedious,  and  the  increased 
compression  of  the  uterine  tissue,  associated  with  the  absence  of 
the  liquor  amnii,  are  also  important  factors.  Moreover,  it  is 
probable  that  in  such  cases  digital  examinations  and  artificial 
delivery  are  more  frequent  than  in  normal  labors,  so  that  the 
introduction  of  infection  may  easily  be  explained.  Blood-clot, 
placental  tissue,  or  portions  of  membranes  retained  in  the  genital 
tract  offer  a  favorable  nidus  for  many  organisms.  All  torn  or 
bruised  surfaces  favor  entrance. 

Frequency. — It  is  difficult  to  estimate  accurately  the  fre- 
quency of  puerperal  infection.  Statistics  as  to  mortality  are  no 
indication,  for  the  morbidit}'  is  much  greater  than  the  mortality. 
Moreover,  it  is  well  known  that  official  vital  statistics  may  be 
incorrect  because  of  false  registration,  puerperal  sepsis  being  fre- 
quently diagnosed  purposely  as  something  else — e.g.,  typhoid  and 
influenza.  It  is  the  general  impression  that  there  has  been  a 
marked  diminution  in  the  mortality  of  puerperal  sepsis  since  the 
introduction  of  antiseptics.  This  is  probably  true  only  as  regards 
hospital  practice.  In  the  Rotunda  Hospital,  Dublin,  during  the 
years  1870-76,  the  mortality  from  puerperal  sepsis  was  i  in  90.9; 
in  1890-96  it  was  i  in  908.5. 

Budin's  statistics  in  1891-97  are  as  follows: 

^      ,  ,.      ,         ■   r      •  Mortality  due  to  infection  in 

Total  mortality  from  infection.  connection  with  delivery. 

Charite  (1891-94) 0.08  per  cent.  0.0    percent. 

Maternite  (1895) 0.46       "  0.27        " 

(1896) 0.39       "  0.15        " 

(1897) 0.27        "  0.07 

Kjelsberg  reports  a  mortality  of  0.15  per  cent,  in  4398  cases 
of  labor  in  the  Christiania  Maternity  in  1891-96.  Mermann  has 
reported  a  series  of  1200  cases  occurring  in  the  Mannheim 
Lying-in  Hospital,  without  one  instance  of  fatal  infection ;  the 
technic  in  these  labors  was  exclusively  aseptic. 

As  regards  private  practice,  it  is  doubtful  if  there  has  been 
much  diminution  in  mortality,  either  in  Europe  or  America.  In 
Great  Britain  this  has  been  demonstrated  by  the  work  of  Boxall, 
CulHngworth,  Williams,  and  others.  Milne  Murray  gives  the  fol- 
lowing' table  : 


PATHOLOGIC  ANATOMY.  64 1 


Mortality  from  Pukrperal  P^kver  in  England  and  Wales. 

Years.  Period.  Mean  deaths  for  1000. 

1847—56  ....  Early  anesthesia,  no  antiseptic 1. 89 

1875-84  ....  Anesthesia  general,  early  antiseptics        ....  2.28 
1886-95  •    •    •    •  Anesthesia  general,  antiseptics  general    ....  2.46 

Boxall  shows  that  while  in  London  the  deaths  in  childbirth 
from  all  causes  has  diminished  considerably  since  antiseptics  came 
into  general  use,  the  reduction  has  scarcely  at  all  been  due  to  a 
lessened  mortality  from  puerperal  sepsis.  In  the  English  counties 
the  death-rate  is  about  the  same  as  it  was  before  the  antiseptic  era. 

Bacon,  in  1 896,  estimated  that  in  Chicago,  during  the  preceding 
forty  years,  12.75  P^^  cent,  of  the  total  mortality  of  women  be- 
tween twenty  and  fifty  years  of  age  died  from  puerperal  sepsis ; 
in  recent  years  the  percentage  has  not  been  so  high.  In  other 
countries  the  frequency  of  puerperal  infection  has  also  been 
noted.  This  lamentable  state  of  matters  is  to  be  explained  as 
follows  :  Midwives  are,  generally  speaking,  very  little  if  at  all 
better  than  they  were  fifty  years  ago.  Of  the  few  who  get  some 
scientific  education,  only  a  small  percentage  ever  attain  to  perfec- 
tion in  the  practice  of  aseptic  obstetrics ;  the  majority  are  even 
more  dangerous  than  those  who  are  untrained,  since,  under  the 
pretense  of  cleanHness,  they  may  work  abominations.  Many 
practitioners  are  guilty  of  the  same  offense.  They  are  even  more 
dangerous  than  the  midwives,  because  of  the  manipulations  they 
are  called  upon  to  perform.  The  abuse  of  anesthesia  is  account- 
able for  much  of  the  puerperal  mortality,  interference  with  the 
course  of  labor  being  much  more  frequent  than  in  the  pre- 
anesthetic days,  when  the  natural  process  was  allowed  to  con- 
tinue as  long  as  possible.  The  lowest  infant  mortality  at  the 
present  time,  speaking  generally,  is  found  in  hospital  practice ; 
next  to  that  comes  that  in  dispensary  practice,  which  is  carried 
on  under  a  rigid  scientific  system.  The  same  results  can  be  ob- 
tained in  private  practice  only  when  practitioners  master  the  prin- 
ciples of  aseptic  technic  and  introduce  them  into  their  work  with 
critical  thoughtfulness  and  exactness. 

Pathologic  Anatomy. — Many  lesions  result  from  puerperal 
infection,  and  these  are  found  with  many  variations  in  different 
cases.  The  changes  may  be  local  or  general,  or  both  of  these 
may  be  combined.  They  may  be  due  to  pyogenic  or  saprophytic 
organisms,  or  to  the  combined  action  of  these.  The  results  of 
infection  depend  on  various  factors — e.g.,  the  nature  and  virulence 
of  the  organism,  the  state  of  the  woman's  health,  the  condition 
of  her  pelvic  tissues,  etc. 

Vulva  and  Vagina. — Infection  of  the  vulva  and  vagina  is  occa- 
sionally found,  producing  patches  which  have  long  been  known  as 
"  puerperal  ulcers."     These  areas  are  torn  or  bruised  surfaces  on 

41 


642  ,.  PUERPERAL   INFECTION. 

which  micro-organisms  have  grown.  They  become  covered  with 
dirty,  yellow-gray,  necrotic  tissue,  which  discharges  pus.  In  some 
cases  these  patches  resemble  those  produced  by  diphtheria.  In 
rare  instances  the  Klebs-Loffler  bacillus  may  be  the  cause  of  these 
patches  ;  ordinarily  it  is  due  to  streptococci.  It  may  also  be 
caused  by  staphylococci,  colon  bacilli,  and  by  anaerobic  putre- 
factive organisms.  The  edge  of  the  patch  is  usually  edematous, 
and  the  swelling  may  extend  from  it  to  a  greater  or  less  extent. 
It  is  rare  that  these  localized  vulvovaginal  infections  are  fatal  or 
serious.  When  marked  disturbances  are  present,  it  is  almost  cer- 
tain that  the  infection  has  spread  to  other  parts. 

Occasionally  the  changes  may  be  of  a  rapid  malignant  type, 
the  superficial  tissues  having  a  gangrenous  appearance.  In  some 
cases  recovery  is  accompanied  with  extensive  sloughing,  and  this 
results  afterward  in  marked  cicatricial  contraction  of  the  passage. 
The  author  observed  one  case  in  which  such  a  process  resulted 
from  streptococcic  infection,  marked  stenosis  of  the  entire  vagina 
afterward  taking  place.  The  vaginal  wall  may  also  be  infected 
without  the  occurrence  of  superficial  necrosis,  the  tissues  being 
reddened,  softened,  and  swollen.  Ischiorectal  abscess  is  some- 
times caused.     Rarely  the  rectal  mucosa  is  infected. 

Cervix  Uteri. — The  cervix  may  undergo  the  various  morbid 
changes  found  in  the  yagina.  The  lacerations  produced  in  labor 
are  frequently  the  site  of  infection,  and  through  them  the  neigh- 
boring tissues  of  the  pelvis  may  be  attacked. 

Uterine  Body. — Various  changes  may  be  found  in  the  uterus 
as  the  result  of  infection,  being  most  marked  and  most  frequent  in 
the  remains  of  the  mucosa.  Both  placental  and  non-placental 
areas  may  be  affected.  The  following  naked-eye  appearances 
may  be  found  :  In  some  cases  the  surface  is  bathed  in  pus.  In 
others  it  is  covered  with  a  dirty,  yellow-gray  membrane,  composed 
mainly  of  necro.sed  decidual  tissue  and  fibrin,  diffused  over  a  wide 
area  or  localized  in  one  or  more  patches.  Sometimes  thick,  shaggy 
masses  may  be  found,  especially  on  the  placental  area  ;  these  may 
contain  fetal  remains  or  may  consist  entirely  of  fibrin  and  shreds 
of  decidua.  In  some  cases  the  lining  of  the  uterus  may  have  a 
dark-green,  gangrenous  appearance.  When  saprophytic  organ- 
isms are  present,  there  is  usually  an  odor,  and  bubbles  of  gas  are 
often  present  in  the  discharges.  It  is  important  to  remember  that 
these  organisms  are  frequently  present  when  true  pyogenic  germs 
are  active.  When  infection  is  alone  due  to  the  latter,  odor  and 
gas  are  usually  absent.  The  uterine  wall  is  enlarged,  relaxed, 
and  softer  than  normal,  in  some  cases  being  very  friable.  This 
relaxation  of  the  wall  undoubtedly  promotes  the  extension  of  in- 
fection, the  diminution  of  pressure  on  the  veins  and  lymph  chan- 
nels making  it  easier  for  micro-organisms  to  pass  along  them. 
Frequently  on  section  small  collections  of  pus  may  be  seen,  usually 


PATIIOLOGIC  ANATOMY.  643 

in  lymphatics  or  in  veins.  In  the  latter  thrombi  sometimes  may 
be  found  in  various  stages  of  suppuration.  True  abscess  forma- 
tion outside  of  the  veins  and  lymphatics  is  very  rare.  Rarely 
extensive  gangrene  or  necrosis  of  a  large  area  of  the  uterine  wall 
occurs,  followed  by  expulsion  through  the  vagina.  By  some  this 
condition  has  been  termed  metritis  dessicans.  On  the  outer  surface 
of  the  uterus  various  stages  of  inflammation  may  be  found  ;  it  may 
sometimes  be  covered  with  a  layer  of  fibrin,  especially  posteriorly. 
Under  the  peritoneum  small  cord-like  elevations  are  sometimes 
present ;  these  are  lymphatics  containing  pus  or  thickened  by 
inflammation.  The  whole  uterus  is  usually  larger  than  normal, 
being  soft  and  flabby  and  easily  indented  by  slight  pressure.  The 
cervical  canal  is  generally  patulous. 

On  microscopic  examination  various  appearances  are  pre- 
sented. In  cases  of  infection  by  streptococci  or  other  pathogenic 
organisms  the  superficial  portion  of  the  endometrium  is  more  or 
less  hyaline  in  appearance  and  stains  badly,  being  altered  by 
coagulation-necrosis.  This  change  is  found  as  a  thin,  irregular 
layer,  being  less  marked  than  in  cases  where  putrefactive  organ- 
isms are  at  work.  Underneath  there  is  a  zone  of  leukocytic  infil- 
tration, varying  in  thickness  and  forming  a  continuous  or  irregu- 
larly broken  layer.  On  the  surface  of  the  endometrium  are 
scattered  the  infecting  micro-organisms  ;  they  are  also  found  in 
the  superficial  necrotic  tissue.  In  some  cases,  especially  those  in 
which  the  organisms  are  not  virulent,  they  are  not  found  deeper 
than  the  leukocytic  layer ;  in  others  they  extend  through  the  latter 
at  various  points,  spreading  especially  through  lymphatics  outward 
into  the  musculature.  In  the  placental  area  the  organisms  may 
be  found  in  the  thrombi  filling  the  divided  sinuses,  extending  also 
inward  along  the  vessels,  producing  inflammatory  changes  in  their 
walls.  In  certain  bad  cases  local  areas  of  liquefaction  may  be 
noticed,  surrounded  by  leukocytes  and  early  abscess  formation. 
These  generally  begin  in  lymphatics,  and  are  especially  found 
under  the  peritoneum.  It  is  impossible  to  describe  accurately  the 
changes  that  occur  in  the  muscle-fibers  themselves.  They  often 
stain  badly  and  present  marked  granular  and  fatty  changes,  but 
the  latter  are  found  in  the  normal  postpartum  uterus.  In  cases 
which  recover  there  may  be  considerable  atrophy  of  muscle  and 
increase  of  the  intermuscular  connective-tissue  elements. 

In  putrid  or  saprophytic  endometritis  the  superficial  necrotic 
layer  is  generally  thick.  If  fetal  remains  are  present,  they  also 
may  show  necrotic  changes.  The  micro-organisms  are  on  the 
surface  as  well  as  in  the  substance  of  the  degenerated  layer.  Below 
the  latter  they  are  usually  not  found,  being  unable  to  penetrate 
the  protective  zone  of  leukocytes. 

In  cases  of  mixed  infection  by  putrefactive  and  septic  organ- 
isms the  former  are  found  mainly  in  the  necrotic  layer,  while  the 


644  '  PUERPERAL    INFECTION. 

latter  may  be  found  under  it,  extending  toward  the  peritoneum. 
Or,  if  two  septic  organisms  are  present,  one  may  remain  super- 
ficial, while  the  more  virulent  may  penetrate  deeply.  In  some 
instances  both  may  be  equally  distributed. 

Tube  and  Ovary. — The  appendages  may  be  affected  by  the 
spread  of  infection  from  the  uterus  along  the  mucosa  or  by  way 
of  the  lymphatics  and  veins  ;  sometimes  from  a  peritonitis.  They 
become  swollen  as  the  result  of  edema,  congestion,  and  small-cell 
infiltration.  Adhesions  may  form  about  them,  and  pus  cavities 
may  form  in  them.  Sometimes  the  tubes  may  be  much  affected 
and  the  ovaries  slightly,  or  vice  versa. 

Parametrium. — Frequently  the  infection  produces  changes  in 
the  various  structures  attached  to  the  uterus,  especially  in  the 
broad  ligaments  ;  they  are  found  in  different  degrees  of  intensity. 
Sometimes  only  a  slight  edema  is  produced.  In  other  cases  there 
may  be  an  extensive  exudation  of  inflammatory  products,  which 
may  afterward  absorb  ;  often  abscess  formation  occurs  in  several 
small  foci,  or  in  one  area,  which  enlarges,  forming  a  large  single 
collection.  These  parametric  processes  frequently  extend  under 
the  peritoneum  in  various  directions — /.  c,  into  the  iliac  fossae, 
along  the  anterior  and  posterior  abdominal  wall,  etc. 

Peritoneum. — The  peritoneum  is  usually  infected  by  trans- 
mission along  the  lymphatics,  but  the  organisms  may  also  pass 
along  the  Fallopian  tubes.  Great  variations  are  found  as  regards 
the  extent  and  nature  of  the  peritonitis  produced  ;  it  may  be  slight 
and  local  or  may  be  extensive.  Serum,  pus,  bloody  pus,  fibrin, 
adhesions,  etc.,  ma)-  be  found.  In  a  considerable  percentage  of 
cases  of  puerperal  infection  septic  peritonitis  is  the  factor  that 
causes  a  fatal  termination. 

Changes  in  the  Circulatory  System. — In  septic  cases  the 
heart  is  frequently  affected.  Degenerative  changes  may  be  found 
in  the  myocardium  ;  endocarditis  sometimes  develops,  pericarditis 
rarely  being  present.  The  walls  of  small  arterioles  may  become 
infected  in  some  cases  ;  they  may  become  blocked  by  masses  of 
organisms,  or,  in  cases  of  endocarditis,  by  portions  of  vegetations. 
The  uterine  veins  may  be  invaded  by  the  organisms  and  the  walls 
altered  by  phlebitis.  This  change  may  spread  beyond  the  uterus 
and  may  affect  the  veins  of  the  broad  or  other  ligaments,  and  may 
extend  along  the  ovarian,  uterine,  internal  iliac,  external  iliac, 
femoral,  and  other  veins  ;  rarely  mesenteric  veins  are  affected. 
The  phlebitis  is  usually  attended  by  thrombosis,  and  the  latter 
may  be  followed  by  suppuration.  Occasionally  a  thrombus  may 
extend  continuously  from  the  uterus  through  the  utero-ovarian 
veins,  vena  cava,  right  side  of  the  heart,  and  pulrtionary  artery. 
In  some  cases  the  thrombi  give  rise  to  embolism.  The  phlebitis 
may  sometimes  not  extend  far  from  the  uterus,  though  the  throm- 
bosis may.     Phlebitis  may,  however,  develop  in  the  lower  limb  or 


PATHOLOGIC  ANATOMY.  645 

elsewhere  in  the  body  in  septic  cases  as  the  result  of  the  trans- 
mission of  infecting  organisms,  not  by  direct  extension  from  the 
uterus.  Frequently  the  infection  causes  marked  changes  in  the 
uterine  lymphatics,  and  the  lymphangitis  may  extend  into  neighbor- 
ing tissues.  Leukocytosis  is  noticed  in  many  cases.  Frequently 
the  spleen  is  enlarged. 

Urinary  Tract. — Sometimes  the  bladder  is  attacked  by  the  in- 
fecting organisms,  which  probably  usually  enter  through  the 
urethra.  The  infection  generally  spreads  upward  to  the  pelvis  of 
the  kidney.  Often  the  epithelium  of  the  kidney  tubules  is  de- 
generated by  the  poisons  circulating  in  the  blood,  produced  by  the 
infecting  organisms. 

Alimentary  Canal. — Definite  changes  in  the  intestine  are 
almost  entirely  limited  to  the  cases  in  which  septic  peritonitis  is 
present.  The  liver  is  often  affected,  degeneration  occurring  in  the 
cells  and  small  hemorrhages  sometimes  taking  place ;  abscesses 
are  rarely  found. 

Respiratory  Tract. — Pleurisy  occasionally  develops,  especially 
when  peritonitis  is  present.  Pneumonia  may  also  occur.  Em- 
bolism may  lead  to  infarct  formation  in  the  lung,  which  may  be 
followed  by  suppuration.  Sometimes  death  may  suddenly  take 
place  from  a  large  embolus  in  the  pulmonary  artery. 

Nervous  System. — Occasionally  cerebral  hemorrhage  may 
cause  death  or  paralysis.  Purulent  meningitis  rarely  occurs. 
Brain  abscess  is  rare. 

Acute  General  Septicemia. — In  some  cases  of  puerperal  in- 
fection, especially  by  virulent  streptococci,  there  may  be  little  or 
no  local  change  in  the  uterus  or  in  other  organs,  because  death 
takes  place  from  the  intensity  of  the  poison  before  any  marked 
alterations  have  had  time  to  take  place.  The  micro-organisms 
are  usually  found  abundantly  in  the  blood  and  different  organs  in 
such  cases. 

Puerperal  Infection  by  Qas=producing  Organisms. — In  cases 
in  which  there  is  infection  by  gas-producing  organisms,  as  long  as 
their  action  is  limited  to  the  uterus  (as  it  is  in  the  majority  of 
cases),  they  produce  only  a  foul-smelling  discharge  containing 
gas-bubbles.  The  latter  are  found  as  well  in  necrotic  tissue  that 
may  lie  on  the  inner  surface  of  the  uterus.  Rarely  the  general 
system  is  invaded,  the  infection  being  carried  by  the  circulation, 
producing  characteristic  changes  in  every  tissue  and  organ  that 
may  be  reached.  They  become  enlarged  by  the  formation  of 
gas,  sometimes  becoming  quite  emphysematous.  The  most  fre- 
quent cause  of  this  condition  is  the  Bacillus  aerogenes  capsulatus. 

Pyemia. — In  some  cases  the  puerperal  infection  becomes 
pyemic  in  type.  This  development  arises  chiefly  from  the  trans- 
mission of  portions  of  thrombi  that  break  down  in  the  uterine 
sinuses   and  veins.     Metastatic   abscesses   may  thus   form   in   all 


646  ^  PUERPERAL   INFECTION. 

parts  of  the  body,  leading  to  more  or  less  destruction  of  tissue 
and  usually  to  the  gradual  disorganization  of  the  patient's  life. 
When  the  infection  leads  to  the  formation  of  a  large  abscess  in 
the  pelvis,  which  becomes  chronic,  the  system  presents  the  ordi- 
nary appearances  produced  by  the  absorption  of  toxins. 

Signs  and  Symptoms. — It  is  evident,  from  the  variety  of 
organisms  which  infect  the  puerperal  woman,  and  from  the  great 
range  of  changes  occurring  in  the  body,  that  many  variations  must 
be  found  in  the  clinical  manifestations  produced.  It  is  best  to 
study  these  in  relation  to  the  pathologic  conditions.  In  the 
common  form  of  septic  infection  commencing  in  the  endometrium, 
symptoms  usually  begin  on  the  third  or  fourth  day,  though  some- 
times not  until  two  or  three  days  later.  During  the  period  imme- 
diately following  labor  the  organisms  multiply  in  the  superficial 
layer  of  the  endometrium,  while  deeper  down  there  is  an  outpour- 
ing of  leukocytes,  forming  a  barrier  or  zone  of  resistance.  In  this 
interval  the  patient  usually  feels  well.  The  first  indication  of 
illness  may  be  a  feeling  of  malaise,  headache,  or  chilliness  ;  there 
may  be  a  marked  rigor,  followed  by  a  rise  in  temperature  and  also 
in  the  pulse-rate.  In  some  cases  more  than  one  severe  chill  may 
occur.  The  temperature  and  pulse  may  remain  elevated  after  the 
first  alteration,  varying  from  time  to  time,  or  they  may  become 
reduced  soon  after  the  early  rise.  The  greatest  differences  are 
found  in  the  temperature,  and  these  are  probably  mainly  due  to 
the  character  and  quantity  of  the  toxins  absorbed  from  the  uterus. 
In  some  instances  hyperpyrexia  may  occur,  the  temperature  reach- 
ing 107°  to  112°  F.  In  most  cases  such  a  rise  indicates  that  death 
is  near,  but  sometimes  the  patient  may  recover  satisfactorily.  It  is 
frequently  as  high  as  103°  F.,  and  may  reach  a  higher  point. 
The  pulse  often  follows  more  or  less  closely  the  temperature 
curve,  but  sometimes  this  relationship  may  not  be  present.  In 
some  cases  the  pulse-rate  may  be  the  chief  indication  of  serious 
danger ;  indeed,  it  may  be  the  first  important  sign.  The  tongue 
usually  becomes  coated,  the  desire  for  food  lessens,  constipation 
is  frequent,  though  sometimes  there  is  diarrhea.  Often,  as  eleva- 
tion of  temperature  continues,  the  milk  secretion  is  diminished. 

The  lochial  discharge  is  frequently  increased  and  may  change 
in  appearance,  owing  to  the  addition  of  yellow  or  white  purulent 
material.  It  has  no  odor  or  only  a  faint  one.  A  fetid  smell  in- 
dicates that  saprophytes  are  at  work,  but  one  must  never  conclude 
from  this  sign  that  septic  infection  is  not  present ;  both  forms  may 
be  combined.  The  blood  in  the  lochial  discharge  may  be  con- 
siderably altered,  becoming  dark  brown  or  chocolate-colored.  In 
some  cases  there  may  be  a  marked  diminution  in  the  quantity  of 
lochia.  This  is  usually  the  case  when  the  temperature  continues 
much  elevated,  though  it  may  sometimes  merely  indicate  an  accu- 
mulation  in  the  uterine  cavity,  which   often   becomes   enlarged. 


SIGNS  AND   SYMPTOMS.  647 

The  uterine  wall  normally  relaxes  somewhat,  its  volume  being  in- 
creased and  its  consistence  less  firm  ;  it  may  be  somewhat  sensitive 
on  palpation.  If  an  intra-uterine  examination  be  made,  the  cervi- 
cal canal  is  found  to  be  patulous  or  easily  dilated.  The  inner  wall 
feels  much  the  same  as  in  non-infected  cases — z.  e.,  the  non- 
placental  area  is  fairly  smooth  and  the  placental  area  is  slightly 


Fig.  267. — Portion  of  placenta  (P)  remaining  ///  utero.  Death  from  sepsis  five  days 
after  delivery  in  a  typhoid  condition.  Colored  girl,  nineteen  years  old,  syphilitic,  with 
dead  fetus  at  term  (Army  Medical  Museum,  Washington,  D.  C.,  No.  7784). 

irregular.     When  remains  of  placenta  or  membranes  are  attached 
to  the  wall,  these  may  be  felt  as  shaggy,  irregular  masses. 

If  putrid  endometritis  be  present  in  a  marked  degree,  superficial 
projecting  portions  of  necrotic  tissue  may  be  felt.    The  symptoms 


648  PUERPERAL   INFECTION. 

associated  with  the  latter  condition  vary  considerably,  and  in  the 
early  stages  may  resemble  those  of  septic  endometritis.  As  the 
case  proceeds  the  general  systemic  disturbances  are  rarely  as 
severe  as  in  the  latter  condition.  When  the  colon  bacillus  or 
Bacillus  aerogenes  capsulatus  causes  the  putrid  endometritis,  there 
will  likely  be  as  well  a  systemic  invasion  by  the  micro-organisms. 
The  ordinary  saprophytes  are,  however,  usually  limited  in  action 
to  the  inner  wall  of  the  uterus,  the  systemic  disturbances  being 
due  to  the  toxins  produced  by  their  action  and  absorbed  into 
the  system. 

The  progress  of  puerperal  endometritis  varies  greatly.  Sub- 
sidence may  be  rapid,  or  gradual  and  prolonged  ;  exacerbations 
may  occur.  In  cases  which  run  a  lengthy  course  the  patient 
becomes  much  reduced  in  strength,  the  various  functions  of  the 
body  being  imperfectly  performed  as  a  result  of  the  continued 
poisoning.  Fatal  cases  are  usually  those  in  which  the  micro- 
organisms have  invaded  the  body  outside  of  the  uterus. 

When  peritonitis  is  present,  the  symptoms  and  signs  vary  ac- 
cording to  the  site,  virulence,  and  extent  of  the  infection.  If 
localized  in  the  pelvis,  pains  may  be  felt  in  that  region,  while  ele- 
vation of  the  pulse  and  temperature  is  marked.  There  is  usually 
much  tenderness  on  palpation,  the  lower  abdominal  region  be- 
coming rigid  on  pressure.  Rigors  are  common.  The  alimentary 
canal  is  disordered  and  vomiting  is  frequent.  When  the  peritoneum 
is  widely  infected,  the  patient's  condition  is  more  serious.  The 
various  changes  need  not,  however,  be  detailed  here,  as  they  are 
well  described  in  works  on  gynecology.  These  cases  are  generally 
fatal,  sometimes  very  rapidly,  within  one  or  two  days.  Ordinarily 
they  last  six  or  seven  days,  rarely  longer.  When  the  tube  and 
ovary  are  infected,  the  symptoms  and  signs  are  the  same  as  those 
occurring  in  any  localized  peritonitis,  considerable  variations  being 
found.  If  at  the  same  time  general  peritonitis  is  present,  it  may 
be  impossible  to  determine  accurately  the  extent  to  which  the 
appendages  are  affected. 

Parametric  infections  are  usually  accompanied  by  marked  dis- 
turbances, especially  when  suppuration  takes  place.  There  are 
marked  elevations  of  temperature  and  local  pelvic  pain.  In 
pyemic  cases,  in  which  uterine  phlebitis  and  breaking  up  of 
thrombi  have  been  followed  by  the  transmission  of  emboli  to 
various  parts  of  the  body,  the  clinical  phenomena  are  too  well 
known  to  need  special  description  here.  They  are  the  same  as 
in  pyemia  developing  from  any  infected  area.  A  condition  of 
hectic  usually  develops,  fever,  chills,  and  remissions  being  noted. 
Disturbances  in  various  organs  and  tissues  maybe  marked — e-g-, 
lungs,  kidneys,  and  joints.  Infection  in  the  urinary  tract  results 
in  disturbances  that  vary  according  to  the  part  affected.  Some- 
times cystitis  is  present;  sometimes  there  is  marked  alteration  in 


PROGNOSIS.  649 

the  kidneys.  Various  changes  in  the  nervous  system  may  be 
found — e.g.,  mental  disturbances,  sleeplessness,  aphasia,  paralyses, 
neuritis,  etc.  In  the  skin  inflammatory  changes  may  be  found — 
e.  g.,  erythematous  and  erysipelatous  patches,  bullae,  abscesses, 
gangrene,  etc.  Occasionally  localized  swellings  due  to  edema 
may  appear  on  different  parts  of  the  body.  It  may  occur  in  the 
lower  extremities,  being  mistaken  for  phlegmasia  alba  dolens. 
Most  frequently  it  is  regarded  as  an  indication  of  abscess  forma- 
tion. The  swelling  is  not  painful  and  may  disappear  in  a  {q.'h 
days. 

Finally  must  be  mentioned  those  cases  of  puerperal  infection 
in  which  an  acute  septicemia  develops  from  the  early  entrance  of 
septic  organisms  into  the  system.  When  this  takes  place  before 
local  changes  have  occurred  in  the  uterus,  the  signs  and  symptoms 
are  the  same  as  those  following  the  introduction  of  infection 
through  any  other  part  of  the  body,  and  are  fully  described  in 
works  on  surgery  and  medicine.  In  the  great  majority  of  cases 
acute  septicemia  is  due  to  streptococcic  infection,  though  it  may 
be  caused  by  other  organisms.  Sometimes  a  gas  bacillus — c.  g., 
Bacillus  aerogenes  capsulatus — may  directly  infect  the  system  in 
addition  to  producing  local  changes  in  the  uterus. 

The  leukocyte  count  is  of  little  value  for  diagnosis  or  prog- 
nosis in  puerperal  infection.  In  normal  conditions  the  number  of 
leukocytes  may  be  as  high  as  is  often  found  in  severe  infections, 
great  variations  being  noted.  In  a  series  of  observations  made 
by  Zweifel  the  count  varied  from  4000  to  21,000.  Moreover,  in 
such  conditions  the  increase  due  to  a  septic  process  may  be  very 
slight. 

Prognosis. — Under  modern  methods  of  treatment  it  is  cer- 
tain that  puerperal  infection,  speaking  generally,  is  less  fatal  than 
in  the  preantiseptic  days.  Severe  types  of  the  affection  are  much 
less  frequent.  The  earlier  the  signs  and  symptoms  of  infection 
appear  after  labor,  the  more  serious  the  case.  The  most  fatal  are 
those  in  which  the  phenomena  develop  within  thirty-six  or  forty- 
eight  hours.  The  outlook  is  very  grave  when  the  peritoneum  is 
infected  or  when  there  is  general  septicemia  ;  the  pyemic  form  is 
very  serious.  When  the  micro-organisms  are  limited  in  their 
activity  to  the  uterus  or  neighboring  parts,  the  outlook  is  hopeful. 
In  the  mildest  cases  it  must  always  be  remembered  that  death  may 
sometimes  follow  suddenly  from  embolism,  though  this  is  rare. 
More  frequently  a  mild  type  may  change  to  a  severe  type  owing 
to  renewed  activity  of  the  micro-organisms  already  present  or  to 
infection  with  others.  It  is  important  also  to  note  that  after- 
results — /.  e.,  chronic  ovaritis,  salpingitis,  etc. — in  cases  which  do 
not  end  fatally  are  often  more  marked  after  mild  infection  than 
after  those  which  are  severe.  The  streptococcus  is  the  most 
common  cause  of  serious  infections,  though  it  varies  greatly  in  its 


650  _^  PUERPERAL   INFECTION. 

manifestations.  The  colon  bacillus  is  frequently  fatal  in  its  action. 
The  gonococcus  and  staphylococcus  in  the  great  majority  of  cases 
produce  local  disturbances  which  rarely  cause  death,  but  often 
lead  to  troublesome  chronic  disturbances.  The  anaerobes  or 
saprophytes  are  usually  the  least  dangerous  infecting  agents,  the 
results  of  their  activity  being  generally  local.  Occasional!}-,  how- 
ever, a  serious  general  infection  may  be  caused — i.  e.,  by  Bacillus 
aerogenes  capsulatus. 

When  infection  is  due  to  more  than  one  organism,  the  prog- 
nosis must  be  more  unfavorable.  When  the  patient  has  been  in 
poor  health,  has  passed  through  a  tedious,  difficult,  or  complicated 
labor  or  has  lost  much  blood,  the  outlook  is  more  serious.  Con- 
tinued high  temperature  or  pulse  indicates  a  serious  condition, 
especially  if  it  persist  after  therapeutic  measures  have  been 
carried  out  to  clean  up  local  infected  areas  in  the  genital  tract. 
Marked  alterations  in  the  kidneys  are  very  unfavorable. 

Diagnosis. — In  the  great  majority  of  cases  it  is  easy  to 
diagnose  puerperal  infection.  Occasionally,  however,  there  is 
difficulty,  especially  in  the  early  stages,  when  there  is  no  localiza- 
tion of  symptoms  or  signs. 

The  greatest  caution  must  be  exercised  in  depending  upon  the 
temperature  and  pulse.  After  labor  these  may  sometimes  be 
elevated  by  causes  other  than  infection.  Thus,  if  delivery  has 
been  very  tedious  and  exhausting,  the  temperature  may  rise  a 
degree  or  a  degree  and  a  half  In  the  succeeding  days  emotional 
excitement  of  any  kind  may  cause  it  to  rise  several  degrees, 
though  it  usually  rapidly  falls  again.  Sometimes  in  nervous 
women  there  may  be  a  simulation  of  rigor.  Undue  distention  of 
the  breasts,  producing  distress,  may  cause  slight  elevation  of  tem- 
perature. If  any  of  the  milk-ducts  be  obstructed,  there  maybe  a 
marked  rise,  especially  in  nervous  women.  In  such  cases,  how- 
ever, it  is  not  always  easy  to  eliminate  the  possibility  of  infection 
in  the  breasts  until  some  hours  have  elapsed.  Normally  there  is 
very  little  rise  in  temperature,  less  than  half  a  degree  or  none  at 
all,  in  connection  with  the  establishment  of  the  milk  secretion. 
The  pulse  usually  corresponds  to  the  temperature  in  these  various 
conditions.  When  much  blood  has  been  lost,  the  pulse  remains 
rapid  after  labor  and  the  temperature  is  more  easily  elevated. 

In  some  cases  it  appears  that  autointoxication  from  the  bowel 
may  cause  an  elevation  of  pulse  and  temperature,  simulating 
infection.  The  s>'mptoms  are  probably  generally  due  to  the 
absorption  of  toxins  produced  by  the  intestinal  micro-organisms. 
Dumont  and  others  believe  that  in  some  cases  colon  bacilli 
actually  pass  into  the  peritoneal  cavity.  Budin  was  the  first  to 
insist  on  this,  in  1892,  and  others  have  made  similar  statements. 
It  is  stated  that  this  trouble  may  arise  both  in  cases  in  which  the 
alimentary  tract  has  been  much  disturbed  during  pregnancy  as 


DIAGNOSIS.  651 

well  as  in  those  in  which  it  has  not.  In  this  condition  there  are 
usually  loss  of  appetite,  malaise,  headache,  flatulence,  distress, 
and  pains  in  the  abdomen.  The  pulse  and  temperature  may  be 
elevated  and  rigors  may  occur.  The  tongue  is  foul,  the  breath 
bad,  and  the  intestines  usually  distended  with  gas.  Distress  may 
be  caused  by  palpating  the  abdomen.  The  administration  of 
purgatives  and  enemata  generally  results  in  large  evacuations,  and 
rapid  improvement  in  symptoms  usually  follows,  though  in  some 
cases  recovery  may  be  slow.  It  is  stated  by  some  that  death  may 
result. 

The  temperature  may  rise  before  an  evacuation  can  be  ob- 
tained, probably  because  the  liquefaction  of  the  feces  caused  by 
the  medicines  allows  more  toxic  matter  to  be  absorbed. 

Septic  inflammation  in  the  breast  may  simulate  infection  through 
the  genital  tract,  and  until  definite  mammary  signs  have  developed, 
there  may  be  great  uncertainty  as  to  the  exact  condition.  It  must 
always  be  remembered  that  occasionally  both  pelvic  and  mammary 
infection  may  be  present.  Sometimes  an  intra-abdominal  infection  ' 
may  follow  injury  to  old  infected  areas — e.g.,  ovaritis,  salpingitis — 
produced  during  labor.  In  such  a  case  the  previous  history 
might  lead  to  a  suspicion  of  the  condition,  while  cultures  from 
the  interior  of  the  uterus  should  be  sterile.  Torsion  of  the  pedicle 
of  tumors  may  also  result  in  changes  that  may  simulate  puerperal 
infection.  A  knowledge  of  the  previous  history  and  careful  ex- 
amination are  necessary  to  make  a  diagnosis.  Malaria  may  some- 
times affect  women  after  labor  and  may  be  mistaken  for  puerperal 
infection.  More  frequently,  however,  the  latter  is  diagnosed  as 
the  former,  often  purposely.  The  diagnosis  of  malaria  should  not 
be  made  unless  the  plasmodia  of  this  disease  are  found  in  the 
blood  and  the  uterine  discharge  is  found  to  be  free  from  infective 
organisms.  Typhoid  fever  is  also  frequently  diagnosed  in  cases 
of  infection,  but  the  diagnosis  should  be  made  only  if  the  Widal 
reaction  is  decided.  This  disease  may  undoubtedly  sometimes 
manifest  itself  in  the  lying-in  woman,  though  rarely.  An  exacer- 
bation of  an  old  tuberculous  lesion  may  sometimes  follow  labop 
and  may  easily  be  mistaken  for  puerperal  sepsis.  Influenza, 
especially  the  atypical  forms,  may  simulate  an  infection. 

It  is  believed  that  the  secondary  streptococcic  or  staphylococ- 
cic infections  that  may  follow  this  disease  may  sometimes  actually 
cause  puerperal  sepsis.  In  all  doubtful  cases  bacteriologic  ex- 
amination of  the  uterine  cavity  should  be  carried  out  where  the 
circumstances  are  favorable  to  this  procedure.  Doderlein's  lochial 
tube  should  be  used  in  collecting  the  fluid  to  be  tested.  It  is 
about  25  cm.  in  length,  4  mm.  in  thickness,  and  is  bent  slightly 
at  one  end.  As  Williams  suggests,  this  is  most  conveniently 
sterilized  and  carried  in  a  large  test-tube,  resting  in  cotton-wool. 
The  patient  should  be  placed  in  the  Sims  or  lithotomy  position 


652  .  PUERPERAL   INFECTION. 

and  the  external  genitals  thoroughly  cleansed.  The  hands  of  the 
operator  and  his  assistants  should  also  be  sterilized.  With  a 
vaginal  speculum,  aided  by  retractors  if  necessary,  the  vagina 
should  be  opened,  the  cervix  drawn  down  with  a  volsella,  and 
wiped  clean  with  sterile  wool.  The  lochial  tube  is  then  removed 
from  the  test-tube  and  its  curved  end  passed  high  into  the  uterus. 
To  its  outer  end  a  piece  of  sterile  rubber  tubing  is  attached,  and 
to  this  a  syringe  is  joined,  for  the  purpose  of  drawing  some  of  the 
uterine  contents  into  the  tube.  The  latter  is  then  withdrawn,  its 
ends  being  closed  with  sealing-wax.  It  is  then  carried  in  its  case 
to  the  laboratory,  where  it  is  broken  across  in  order  that  cultures 
may  be  taken  from  the  contents  and  slides  examined. 

Treatment. — Prophylactic. — Bearing  in  mind  that  in  the 
great  majority  of  cases  infection  is  due  to  carelessness  in  the 
technic  observed  during  deliveiy,  the  physician  should  insist  on 
the  observance  of  the  same  rigid  measures  by  those  who  assist 
him  as  well  as  by  himself  which  would  be  enjoined  by  a  careful 
surgeon  in  the  conduct  of  a  surgical  case.  The  necessary  measures 
have  already  been  detailed  in  the  chapters  dealing  with  the 
management  of  pregnancy  and  labor,  and  need  not  again  be 
repeated. 

Curative. — When  the  perineum  or  lower  part  of  the  vagina  is 
infected,  it  is  necessaiy  to  destroy  the  organisms  as  soon  as  pos- 
sible, in  the  hope  that  they  may  be  prevented  from  spreading 
upward  into  the  uterus.  For  this  purpose  the  author  has  em- 
ployed the  following  plan  :  The  patient  is  placed  in  the  lithotomy 
position  and  the  vagina  exposed,  the  affected  area  being  washed 
with  50  per  cent,  peroxid  of  hydrogen  solution.  A  gauze  tampon 
is  then  placed  in  the  vagina,  soaked  in  a  solution  of  formalin  in 
glycerin  and  water  (formalin,  Ttlxxx ;  glycerin,  5iv ;  sterile  water, 
Oj).  After  twelve  hours  the  gauze  is  withdrawn,  the  affected 
parts  again  washed  with  peroxid,  and  fresh  formalin  gauze  re- 
introduced for  twelve  hours.  This  may  again  be  repeated  until 
the  infected  area  is  in  a  healthy  healing  condition.  This  method 
•is  preferable  to  the  employment  of  antiseptic  douches,  because  it 
allows  of  the  continuous  application  of  a  powerful  penetrating 
antiseptic. 

When  the  uterine  cavity  is  infected,  it  is  important  to  determine 
the  condition  of  the  uterus  and  of  the  entire  contents  of  the  pelvis. 
Some  discharge  should  be  first  collected  in  a  glass  tube,  from  the 
interior  of  the  uterus,  in  the  manner  already  described.  A  thor- 
ough bimanual  examination  should  be  made  to  determine  the 
condition  of  the  ovaries,  tubes,  peritoneum,  and  parametrium. 
One  or  two  fingers  should  then  be  introduced  into  the  uterus  to 
palpate  its  inner  wall  and  to  determine  whether  there  is  much 
debris  in  the  cavity.  If  the  wall  has  no  abnormal  masses  attached 
to  it,  the  debris  in   the  cavity  should  be  simply  washed  out  witli 


TREA  TMENT.  6$  3 

normal  salt  solution.  Curettage  is  not  indicated  in  such  a  condi- 
tion ;  it  is  indeed  an  unwise  procedure.  The  infecting  organisms  in 
such  a  case  are  mainly  in  the  superficial  layer  of  the  endometrium, 
while  leukocytes  are  accumulated  in  a  deeper  zone  as  a  line  of 
first  defense.  In  the  great  majority  of  cases  this  protecting  zone 
is  not  penetrated,  or  is  to  such  a  small  extent  that  serious  systemic 
invasion  does  not  occur.  Curettage  is  dangerous,  because  it 
breaks  up  this  protecting  zone,  exposing  fresh  raw  tissue,  which  is 
likely  to  be  invaded  by  the  micro-organisms,  which  cannot,  of 
course,  be  entirely  removed  by  the  curet. 

The  inner  wall  of  the  uterus  should  indeed  be  disturbed  as 
little  as  possible.  The  author  strongly  advises  introducing  into 
the  uterine  cavity  gauze  soaked  in  an  antiseptic  solution  that 
is  penetrating  and  not  dangerous  to  the  system  in  the  strength  in 
which  it  is  employed.  For  several  years  he  has  employed  the 
glycerinated  formalin  solution  referred  to  above.  The  gauze  is 
left  in  the  uterus  about  twelve  hours,  a  fresh  piece  being  then  in- 
troduced. This  procedure  may  be  repeated  one  or  more  times  if 
the  patient's  condition  does  not  rapidly  improve.  In  cases  in 
which  the  organisms  have  not  passed  beyond  the  uterus  it  is 
rarely  necessary  to  use  more  than  one  or  two  applications  of  the 
gauze.  When  there  is  evidence  of  general  systemic  invasion  or 
of  pelvic  infection  external  to  the  uterus — /.  e.,  parametritis, 
salpingitis,  etc. — it  is  useless  to  continue  the  intra-uterine  appli- 
cations. 

The  author  has  entirely  abandoned  the  use  of  intra-uterine 
antiseptic  douches  in  these  cases,  because  it  has  been  abundantly 
proved  that  the  temporary  dribble  of  such  a  stream  is  utterly 
without  destructive  or  inhibitory  effect  on  the  micro-organisms,  so 
many  of  which  are  not  on  the  surface,  but  in  the  tissues.  More- 
over, it  has  been  clearly  shown  that  the  employment  of  salts  of 
mercury,  so  frequently  employed  in  intra-uterine  douches,  is  not 
without  risk,  several  deaths  having  indeed  been  reported  in  recent 
years.  There  is  indeed  no  place  for  the  use  of  these  salts  or  of 
others  that  are  likely  to  damage  the  tissues  or  poison  the  system. 
Schucking's  method  of  irrigating  the  uterine  cavity  continuously 
with  an  antiseptic  lotion  is  rational  if  a  solution  be  used  that  will 
not  injure  the  tissues  or  poison  the  system.  Though  it  has  been 
enthusiastically  adopted  in  some  quarters,  it  has  not  been  favorably 
received  by  the  profession,  on  account  of  the  inconvenience  asso- 
ciated with  its  employment.  The  author's  plan  of  using  a  tampon 
soaked  in  an  antiseptic  is  a  simpler  method,  and  is  suitable  to 
private  as  well  as  to  hospital  practice.  The  plan  of  swabbing  out 
the  uterus  with  strong  solutions — z.  e.,  corrosive  sublimate,  car- 
bolic acid,  formalin,  etc. — is  to  be  condemned,  because  of  the  de- 
struction of  tissue  that  is  produced.  No  such  risks  exist  with  the 
use  of  gauze  soaked  in  the  solution  of  formalin  that  I  have  em- 


654  -  PUERPERAL   INFECTION. 

ployed.  In  a  number  of  cases  I  have  used  chinosol  solution 
(i  :  looo)  with  satisfactory  results,  but  I  believe  the  former  solu- 
tion to  be  more  penetrating. 

When  the  wall  is  abnormally  rough  and  shaggy  and  the  lochial 
discharge  has  an  odor,  it  should  be  scraped  with  the  fingers  and 
the  debris  should  be  washed  out  of  the  uterus  with  a  stream  of 
normal  saline  solution  or  swabbed  out  with  pieces  of  gauze  held 
in  forceps.  If  the  projecting  masses  are  not  completely  removed 
in  this  way,  a  curet  forceps  should  be  employed.  Occasionally  it 
may  be  necessary  as  well  to  use  a  curet.  Afterward  gauze  soaked 
in  the  glycerinated  formalin  solution  should  be  introduced  into 
the  cavity  for  twelve  hours  and  then  changed. 

In  all  cases  of  infection  of  the  uterus  ergot  should  be  admin- 
istered to  counteract  the  tendency  to  relaxation  in  the  uterus,  in 
order  that  the  lymphatics  and  veins  may  be  compressed  and  so 
rendered  less  liable  to  convey  infection.  When  there  is  evidence 
of  localized  pelvic  inflammation  beyond  the  uterus,  an  ice-water 
coil  may  be  placed  on  the  lower  abdominal  region,  the  water  being 
allowed  to  circulate  continuously  through  it.  Many  prefer  to  use 
hot  fomentations  rather  than  cold,  patients  usually  preferring  the 
former.  When  there  is  evidence  of  general  intoxication  from 
toxins,  or  of  an  active  general  septic  process,  it  is  important  to 
keep  up  the  patient's  strength  by  easily  digested  nourishing  food 
— /.  r.,  milk,  plain  or  peptonized;  plasmon,  beef-juice,  etc.  Of 
great  value  are  high  rectal  injections  of  warm  normal  saline  solu- 
tion (a  pint  ever}'  five  or  six  hours).  This  fluid  has  a  certain 
food  value,  is  a  stimulant,  promotes  the  activity  of  the  kidneys  and 
skin,  and  dilutes  toxins  circulating  in  the  system.  If  sodium  ace- 
tate be  added  to  it,  the  diuretic  action  is  increased.  The  bowels 
should  be  kept  regularly  open.  Brandy  or  whisky  is  valuable 
where  there  is  much  exhaustion  and  when  abundant  nourishment 
must  be  supplied  continuously  to  make  up  for  excessive  waste  of 
tissue.  As  much  as  lo  or  12  oz.  or  even  more  may  be  admin- 
istered in  twenty-four  hours,  chiefly  for  the  food  value,  though 
the  stimulant  action  is  also  important.  One  of  the  best  stimulants 
for  impaired  cardiac  action  is  strychnin  given  in  large  doses.  The 
antipyretics  that  are  so  widely  employed  are  inadvisable,  as  they 
are  apt  to  depress  the  patient.  Hydrobromate  of  quinin  may, 
however,  be  given  (3  to  5  gr.  three  or  four  times  a  day)  without 
causing  depression  or  any  disturbance.  When  the  fever  is  high, 
the  cold  pack,  cold  sponging,  or  cold  baths  are  valuable,  causing 
the  same  benefits  as  in  the  treatment  of  typhoid  fever.  The  baths 
should  not  be  used  if  there  be  peritonitis,  a  pelvic  exudate,  or 
phlegmasia  alba  dolens.  Mace,  an  enthusiastic  advocate  of  the 
bath,  recommends  that  the  water  should  be  at  about  75°  F.,  the 
same  precautions  being  observed  as  in  the  treatment  of  typhoid. 

In  1886  Schultze,  of  Jena,  performed  hysterectomy  in  a  case 


TREA  TMENT.  65  5 

of  retained  placenta  with  infection,  and  since  that  time  the  opera- 
tion has  been  carried  out  in  puerperal  infection  by  several  workers. 
At  present  it  is  little  practised,  because  it  is  difficult  to  establish 
definite  indications  for  its  performance.  Extensive  infection  of 
the  uterine  wall,  with  abscess  formation,  is  considered  by  some  a 
suitable  indication,  and  indeed  it  may  be  so  regarded,  but  unfor- 
tunately, when  this  condition  exists,  the  whole  system  is  likely  to 
be  invaded  by  infecting  organisms,  which  will  continue  to  be 
active  after  the  uterus  is  removed.  If,  however,  there  is  consider- 
able certainty  that  they  are  mainly  localized  in  the  uterus,  vaginal 
hysterectomy  may  be  advisable.  The  general  condition  of  the 
patient  should  be  such  as  to  warrant  its  performance.  Bonamy 
has  collected  31  operations,  in  which  11  deaths  occurred;  Treub, 
36  cases,  in  which  21  deaths  resulted.  The  latter  author  states 
that  he  has  treated  734  cases  of  puerperal  infection,  with  34 
deaths.  In  6  of  the  latter  there  were  no  clinical  signs  of  any 
infection  outside  of  the  uterus,  but  the  autopsies  revealed  nephritis, 
purulent  thrombosis,  or  other  serious  lesions  in  all  but  2  cases. 
Consequently,  out  of  the  34  fatal  cases,  probably  only  2  might 
have  been  saved  by  hysterectomy.  He  holds  that  there  is  no 
absolute  indication  for  the  performance  of  this  operation. 

When  abscesses  form  in  one  or  other  of  the  pelvic  tissues 
and  their  presence  is  clearly  indicated,  evacuation  of  the  pus  is 
necessary.  This  should  be  carried  out  by  the  vaginal  route,  if 
possible,  even  when  the  tubes  or  ovaries  are  infected.  Removal  of 
diseased  tubes  and  ovaries  by  the  abdominal  or  vaginal  incision  is 
very  risky  while  the  tissues  are  invaded  with  active  infective  organ- 
isms. This  radical  procedure  should  be  deferred  as  long  as  possible. 

When  general  septic  peritonitis  is  present,  the  treatment  is  the 
same  as  in  non-puerperal  varieties  of  this  affection.  Apart  from  the 
general  measures  already  described,  there  is  considerable  difference 
of  opinion  as  to  the  course  to  be  adopted.  The  author  recom- 
mends a  mesial  abdominal  incision  for  the  purpose  of  washing  out 
the  belly  with  normal  saline  solution  containing  formaUn  (16 
minims  of  formalin  to  a  pint).  If  there  be  a  tubal  or  ovarian 
abscess,  it  should  be  removed.  A  wide  opening  should  then  be 
made  into  the  vagina  through  the  pouch  of  Douglas.  If  the 
uterus  presents  suppurating  foci,  it  should  be  removed.  Chinosol 
gauze  should  then  be  packed  in  the  pelvis,  its  lower  end  being 
placed  in  the  vagina.  A  glass  drainage-tube  should  be  placed  in 
the  anterior  abdominal  incision.  Through  it  the  formalin  saline 
solution  should  be  injected  twice  daily  until  improvement  is 
noticeable ;  the  abdominal  incision  should  then  be  closed.  On 
the  third  or  fourth  day  a  new  piece  of  gauze  may  be  introduced 
into  the  pelvis  through  the  vagina,  or  douches  of  formalin  solu- 
tion may  be  used. 

Within   recent  years  considerable  attention  has  been  given  to 


656  ^  PUERPERAL    INFECTION. 

the  subject  of  serum  therapy  in  puerperal  infection.  In  1891 
Lingelsheim  and  Roger,  and  in  1893  Mironoff,  believed  that  they 
partly  succeeded  in  immunizing  animals  against  streptococcus. 
In  1895  Marmorek  reported  that  by  growing  streptococcus  on 
blood-serum  and  agar  and  inoculating  animals  repeatedly,  so  as 
to  obtain  a  very  virulent  culture,  he  was  able  by  injecting  this 
culture  into  immune  animals  to  produce  a  preventive  and  curative 
serum.  Charrin  and  Roger  at  the  same  time  reported  a  similar 
serum,  obtained  in  a  somewhat  different  manner. 

Many  reports  have  appeared  in  different  countries  regarding 
the  hypodermic  injection  of  antistreptococcic  serum.  Glowing 
accounts  of  single  cases  in  which  improvement  followed  its  em- 
ployment have  been  given  in  many  journals ;  they  are  mostly 
worthless.  Accurate  studies  of  many  cases  by  skilled  observers 
make  it  evident  that  no  better  results  have  attended  the  use  of 
the  serum  than  have  followed  other  methods  of  treatment.  In 
1899  a  committee  of  the  American  Gynecologic  Society  issued  a 
report  on  this  subject.  They  collected  352  cases  of  puerperal 
infection  in  which  the  serum  had  been  used.  Of  these  it  was 
certain  that  there  was  streptococcic  infection  only  in  loi  cases,  of 
which  33  died,  or  32.69  per  cent.  Kronig  has  treated  56  and 
Williams  52  cases  of  streptococcic  endometritis  without  the  serum 
with  a  mortality  of  less  than  4  per  cent.  The  author  has  treated 
more  than  160  cases  with  little  more  than  5  per  cent.,  the  mor- 
tality being  chiefly  due  to  peritonitis  where  operation  was  not 
carried  out.  If  it  be  admitted  that  the  antistreptococcic  serum 
may  do  good  in  cases  of  streptococcic  infection,  it  is  irrational  to 
suppose  that  it  is  valuable  where  other  organisms  are  the  cause 
of  trouble.  Yet  it  has  been  used  indiscriminately,  and  success 
has  been  claimed  for  it  in  saprophytic  as  well  as  in  the  various 
forms  of  septic  infection,  when  improvement  has  been  undoubt- 
edly due  to  other  factors.  Bar  and  Tissier  have  called  attention 
to  the  various  complications  that  have  followed  the  use  of  the 
serum — /.  e.,  distress,  malaise,  shivering,  rise  of  temperature, 
erythema,  urticaria,  pains  in  joints,  effusion  in  joints,  and  abscess. 

Hofbauer  has  advised  the  use  of  nuclein,  claiming  that  it  in- 
creases the  number  of  leukocytes  and  so  leads  to  improvement. 

Phlegmasia  Alba  Dolens  (Milk  I^eg;  White  Swell- 
ing").— Though  this  condition  is  a  form  of  puerperal  infection,  it 
is  usually  considered  by  itself.  It  may  accompany  other  mani- 
festations of  infection,  but  frequently  it  is  the  only  evident  result, 
and  is  often  first  noticed  only  after  the  first  or  second  week  of  the 
puerperium.  The  left  limb  is  more  frequently  affected  than  the 
right ;  sometimes  both  limbs  are  involved.  In  the  great  majority 
of  cases  the  condition  is  due  to  phlebitis,  starting  in  uterine  veins 
and  extending  into  the  iliac  vein,  thrombosis  occurring  as  well  in 
the  femoral  or  saphenous  veins.     Thrombosis  is  usually  due  to 


PHLEGMASIA   ALBA    DOLENS.  657 

the  direct  influence  of  the  phlebitis,  but  may  also  be  produced  by 
the  toxins  of  the  infecting  organisms.  The  veins  of  the  lower 
limbs  are  favorable  to  thrombosis  because  they  are  often  dilated 
and  varicose,  the  blood-current  being  sluggish.  The  increased 
fibrin-forming  tendency  of  the  blood  of  the  lying-in  woman  is 
another  favoring  factor.  Occasionally  there  may  be  an  indepen- 
dent distinct  phlebitis  in  the  femoral,  external,  or  internal  saphe- 
nous veins,  not  continuous  with  inflammation  in  the  iliac  or  uterine 
veins.  This  was  formerly  believed  to  be  the  common  cause  of 
phlegmasia,  but  it  is  now  known  to  be  rare.  Sometimes  there 
may  be  an  associated  involvement  of  superficial  veins  on  the 
anterior  abdominal  wall.  The  venous  changes  may  be  accom- 
panied by  lymphatic  infection  that  has  extended  from  the  uterus, 
and  marked  obstruction  to  the  flow  of  the  lymph  in  the  lower 
limb  may  be  caused.  Sometimes  the  cellular  tissue  external  to 
the  lymphatics  may  also  be  injected.  In  some  cases  the  lymphatics 
of  the  upper  part  of  the  thigh  are  alone  involved,  the  veins  re- 
maining healthy,  the  swelling  of  the  limb  being  entirely  due  to 
the  obstructed  lymph  current,  the  inguinal  lymphatic  glands 
being  enlarged  and  sensitive  in  some  cases. 

Symptoms  and  Signs. — Pain  is  generally  the  first  symptom. 
It  is  usually  felt  in  the  groin,  along  the  course  of  the  femoral 
or  saphenous  vein,  or  in  the  calf,  great  variations  being  found  in 
its  severity.  Sometimes  it  is  sharp  and  intense ;  sometimes  it  is 
merely  a  dull  ache.  On  moving  the  limb  or  on  standing  the  dis- 
tress is  increased.  The  easiest  position  is  one  of  slight  flexion 
with  internal  rotation  of  the  thigh.  Swelling  of  the  limb  usually 
follows  the  pain,  though  sometimes  it  occurs  first.  In  some  cases 
the  eye  fails  to  detect  any  difference  in  the  size  of  the  limbs,  and  care- 
ful measurements  are  necessary  to  determine  the  enlargement.  In 
some  cases  the  swelling  appears  first  at  the  ankle  or  calf  and  spreads 
upward  ;  in  others  it  begins  in  the  groin  and  extends  downward. 

In  the  majority  of  cases  the  swelling  is  due  to  edema  of  the 
tissues  from  venous  obstruction.  When  the  lymphatics  are  in- 
volved, their  engorgement  adds  to  the  swelling.  In  extreme  cases 
the  whole  limb  may  be  enormously  enlarged.  The  skin  becomes 
stretched,  pearly  white,  and  glistening,  with  often  a  marbled  ap- 
pearance. Sometimes  thickening  and  redness  may  be  visible 
along  the  line  of  inflamed  veins.  When  there  is  superficial  lymph- 
angitis, the  skin  may  also  be  reddened.  The  edematous  tissues 
pit  on  pressure.  When  the  superficial  swelling  is  partly  or  wholly 
due  to  lymphatic  engorgement,  the  skin  feels  firm  and  brawny  and 
cannot  be  indented  like  tissues  enlarged  by  edema.  Palpation  of 
the  limb  usually  causes  distress,  which  varies  in  different  cases  ; 
it  is  chiefly  marked  along  swollen  veins,  especially  when  inflamed. 
Areas  of  lymphangitis  are  also  usually  painful  to  the  touch. 
Edematous   cellular  tissue   is   not  sensitive  to  pressure,  as  a  rule, 

42 


658  ^  PUERPERAL    INEECTION. 

unless  the  swelling  be  very  marked.  The  affected  veins  may  in 
parts  be  easily  palpated,  save  when  the  tissues  external  to  them 
are  much  swollen.  When  there  is  phlebitis  of  the  external 
saphenous,  it  is   usually  felt  at  the  top  of  the  calf. 

The  limb  is  usually  less  sensitive  to  touch  and  to  heat,  though 
when  the  swelling  is  excessive  there  may  be  hyperesthesia.  The 
general  condition  of  the  patient  varies  considerabl}^  When  the 
phlegmasia  is  the  sole  or  chief  manifestation  of  infection,  she  is 
not  greatly  disturbed  so  long  as  she  keeps  quiet.  The  temperature 
is  elevated,  though  not  generally  to  a  marked  extent.  When  there 
is  marked  phlebitis  or  lymphangitis,  more  or  less  disturbance  of 
functions  usually  occurs — e.g.,  loss  of  appetite,  foul  tongue,  dis- 
ordered stomach  and  bowels,  general  malaise,  and  sleeplessness. 
Occasionally  at  the  beginning  of  the  affection  there  may  be  marked 
disturbance  and  pains  in  the  chest,  due  to  emboli,  which  may 
cause  pleurisy  or  lung  infarcts. 

The  progress  of  the  disease  varies  greatly.  In  most  cases  there 
is  complete  subsidence  in  three  to  six  weeks,  the  swelling  and 
temperature  gradually  disappearing.  In  some  cases  there  are  ex- 
acerbations from  time  to  time.  Occasionally  the  swelling  lasts 
only  a  few  days.  In  some  cases  recovery  is  followed  by  chronic 
swelling  of  the  limb,  which  may  last  for  months  or  years.  In  the 
course  of  the  trouble  various  complications  may  arise — /.  c, 
erysipelatous  inflammation  in  the  skin,  gangrene,  abscess,  and 
embolism.  Permanent  lameness  and  weakness  may  sometimes 
result  from  muscular  atrophy. 

Treatment. — The  patient  should  be  placed  on  her  back  in  bed, 
the  affected  limb  being  enveloped  in  wool,  elevated  on  pillows, 
and  kept  at  rest.  She  should  remain  in  this  position  for  several 
weeks — ordinarily,  three  or  four  after  the  onset  of  the  trouble. 
She  should  not  be  allowed  out  of  bed  until  ten  days  have  passed 
after  tenderness,  fever,  and  swelling  have  disappeared.  On  sitting 
up  the  limb  should  be  kept  horizontal  most  of  the  time,  and  should 
only  gradually  be  used  in  standing  or  walking. 

The  diet  must  be  nourishing  and  the  bowels  must  be  well  regu- 
lated. When  the  bedpan  is  used,  great  caution  must  be  exercised. 
Movements  may  detach  portions  of  thrombi  and  lead  to  embolism, 
and  the  patient  should  be  warned  against  making  them.  When 
the  patient  is  allowed  to  sit  up,  gentle  massage  may  be  carried  out 
for  a  few  weeks,  in  order  to  improve  the  circulation  and  the 
tissues.  During  the  progress  of  the  disease  it  may  be  necessary 
to  use  drugs  to  lessen  the  pain.  These  may  be  applied  locally  or 
internally.  Applications  of  lead  and  opium  lotion  are  usually 
satisfactory,  but  must  be  applied  without  moving  the  limb.  Oc- 
casionally hypodermic  doses  of  morphin  may  be  necessary. 
Complications  must  be  treated  as  they  arise ;  thus,  if  abscesses 
form  in  the  limb,  they  should  be  incised. 


PART    VII. 

OPERATIVE  OBSTETRICS. 


CHAPTER    I. 
ARTIFICIAL  INTERRUPTION  OF  PREGNANCY. 

Abortion. — The  interruption  of  pregnancy  before  the  time  of 
viability  of  the  fetus  may  be  justifiable  for  a  variety  of  reasons. 
The  procedure  should  never  be  undertaken  without  the  gravest 
consideration,  and  only  because  of  reasons  that  are  entirely  medi- 
cal. The  mere  desire  of  a  pregnant  woman  that  gestation  should 
be  ended  should  never  influence  a  physician  in  the  slightest  degree. 
In  every  instance  in  which  he  may  consider  it  necessary  he  should 
seek  consultation  with  one  or  more  medical  men,  not  only  that 
the  matter  may  be  thoroughly  discussed,  but  as  well  that  he  may 
be  protected  from  any  suspicion  of  wrongdoing. 

Indications. — The  conditions  that  may  render  necessary  the 
induction  of  abortion  have  already  been  referred  to  in  connec- 
tion with  "  Pathology  of  Pregnancy,"  and  need  here  only  be  re- 
capitulated in  a  general  way. 

1.  Certain  disorders  of  the  nervous  system — e.  g.,  very  bad 
chorea. 

2.  Certain  disorders  of  the  hemopoietic  and  circulatory  sys- 
tems— e.  g.,  large  and  rapidly  growing  thyroid,  pernicious  anemia, 
and  some  conditions  of  valvular  heart  disease. 

3.  Certain  lung  diseases — e.  g.,  some  conditions  of  phthisis. 

4.  Certain  affections  of  the  alimentary  system — e.  g.,  severe 
pernicious  vomiting,  endangering  the  woman's  life. 

5.  Certain  diseases  of  the  urinary  system — e.g.,  marked  renal 
inflammation  and  degeneration. 

6.  Certain  diseased  states  of  the  uterus — e.  g-,  conditions  lead- 
ing to  marked  loss  of  blood,  some  forms  of  new  growth,  and  in- 
carcerated retroflexion. 

7.  Certain  diseases  and  abnormalities  of  the  ovum — e.g.,  hydat- 
idiform  degeneration  of  the  chorion,  placenta  praevia,  detachment 
of  the  normally  situated  placenta,  and  death  of  the  embryo. 

659 


66o 


ARTIFICIAL    INTERRUPTION  OF  PREGNANCY. 


8.  Pelvic  deformities.  In  extreme  degrees  of  pelvic  contraction 
abortion  may  be  considered  as  an  alternative  to  measures  that 
must  perforce  be  employed  if  pregnancy  is  allowed  to  go  to  full 
term.  The  period  at  which  the  abortion  should  be  performed  in 
such  cases  depends  on  the  size  of  the  pelvis.  Lusk  gives  the 
following  table : 

Anteroposterior  diameter  Latest  period  for  inducing 

■    of  pelvis.  abortion. 

I.J-  in Beginning  of  the  sixth  month. 

li  in "  "        fifth 

I   in ....       Four  months  and  a  half. 

As  De  Soyre  points  out,  with  less  than  an  inch  the  difficulties 
of  inducing  abortion  are  so  great  as  to  make  the  operation  inad- 
visable. 

Methods  of  Inducing  Abortion. — Very  many  procedures  have 
been  tried.     The  administration  of  drugs — /.  e.,  ergot,  cotton-root 


Fig.  268. — Bougie  passed  through  cervi.x  and  between  membranes  and  uterine  wall, 
and  retained  by  a  light  vaginal  tampon. 

bark,  quinin,  pilocarpin,  aloes,  and  various  essential  oils — /.  r.,  rue, 
savin,  tansy,  parsley,  and  pennyroyal — is  uncertain,  unreliable, 
and  frequently  dangerous.  No  drug  can  be  relied  on  to  produce 
abortion  ;  the  uterus  is  rarely  completely  emptied  after  their  use. 
Incomplete  abortion  is  frequently  associated  with  hemorrhage  and 
with  septic  infection.  Sometimes  harm  results  from  the  large 
doses  administered. 

The  induction  of  abortion  by  the  administration  of  large  doses 
of  purgatives,  producing  reflex  stimulation  of  the  uterus,  is  un- 
justifiable. Massage  of  the  nipples,  as  recommended  byScanzoni, 
is  not  to  be  recommended.  Galvanism  applied  to  the  uterus  is 
rarely  practical  and  is  uncertain.  Kiwisch's  method  of  douching 
the  upper  part  of  the  vagina  and  cervix  with  hot  water  (105°  to 
108°  F.)  is  very  uncertain  and  tedious.  The  injection  of  fluids 
into  the  uterus,  outside  of  the  membranes,  is  slow  and  risky ;  it 


ABORTION.  66 1 

has  frequently  been  followed  by  infection  and  sometimes  by  air 
embolism.  A  favorite  method  has  long  been  the  introduction  of 
a  flexible  catheter  or  bougie  into  the  uterus,  outside  of  the  mem- 
branes. It  should  not,  however,  be  employed.  It  may  be  very 
difficult  to  introduce  the  instrument  without  perforating  the 
amnion.  The  catheter  should  not  be  used,  because  it  contains 
air;  the  bougie  may  perforate  the  uterus.  The  results,  moreover, 
are  very  uncertain.  Sepsis  has  frequently  been  introduced  by  this 
method,  which  necessitates  the  retention  of  the  instrument  in  the 
uterus  twelve  or  more  hours. 

The  passage  of  a  sound  into  the  uterus  is  very  uncertain  in  its 
effects  ;  in  unskilled  hands  it  may  cause  perforation  of  the  uterus. 
Frequently  abortion  may  not  be  started  until  the  instrument  has 
been  passed  on  successive  days  ;  the  woman  is  thereby  exposed 
to  increased  risk  of  infection. 

Removal  of  the  liquor  amnii  by  direct  puncture  or  by  aspira- 
tion is  also  an  uncertain  method  ;  abortion  may  start  in  a  few 
hours  or  may  be  delayed  one  or  more  days.  Moreover,  the  ab- 
sence of  the  liquor  amnii  makes  it  more  difficult  for  the  uterus  to 
expel  the  contents  satisfactorily.  Portions  of  the  ovum  are  apt 
to  be  retained.  In  cases  where  pains  do  not  occur  until  after  an 
interval  of  some  days  the  risk  of  septic  infection  in  the  uterus  is 
considerable.  It  has  been  recommended  by  several  that  the 
membranes  should  be  punctured  some  distance  above  the  os  in- 
ternum, so  that  some  fluid  might  be  retained  to  act  as  a  dilator. 
This  procedure  cannot,  however,  be 
carried  out  with  ease  and  certainty, 
and  should  be  attempted  only  by  ex- 
perts. 

Tamponade  of  the  vagina  by  means 
of  gauze  or  cotton  tampon  or  a  rubber 
bag — e.  £■.,  Braun's  colpeurynter — is  a 

very  unreliable  method.    In  some  cases  fig.  269.— Colpeurynter. 

it  will  not  induce  abortion   at  all.     It 
is  tedious  and  often  makes  the  vagina  very  sensitive  or  painful. 

The  following  procedures  are  most  satisfactory  : 

I.  During  the  First  Three  Months  of  Pregnancy. — {a)  Emptying 
the  Uterus  at  One  Sitting. — In  the  great  majority  of  cases  it  is 
possible  to  dilate  the  cervix  so  that  the  uterine  contents  may  be 
removed  with  one  or  two  fingers  and  with  the  abortion-  or  curet- 
forceps.  If  sufficient  dilatation  cannot  be  obtained  for  the  intro- 
duction of  one  or  two  fingers,  the  curet  forceps  alone  may  be 
employed.  The  patient  should  be  anesthetized,  placed  in  the 
lithotomy  position,  and  prepared  with  the  same  care  observed  in 
a  surgical  operation,  the  bladder  and  rectum  having  been  emptied. 
If  a  general  anesthetic  is  contraindicated,  cocain  may  be  injected 
into  the  cervix  {\  gr.  in  solution  in  each  side),  in  order  to  render 


662  ARTIFICIAL    INTERRUPTION   OF  PREGNANCY. 

dilatation  less  painiul.  The  operator  and  his  assistants  must  like- 
wise be  rigid  in  regard  to  aseptic  technic.  The  cervix  should  be 
held  by  a  tenaculum  and  gradually  dilated  by  a  series  of  graduated 
metal  dilators.  Caution  should  be  exercised,  in  order  that  the 
wall  should  not  be  torn  to  any  marked  extent.  In  the  third 
month  the  canal  may  sometimes  be  dilated  sufficiently  to  allow 
the  entrance  of  two  fingers  without  tearing  of  the  wall.  Usually, 
however,  this  degree  of  enlargement  is  not  obtained.  In  the  first 
two  months  it  is  not  advisable  or  necessary.  After  dilatation  the 
amniotic  fluid  should  be  evacuated,  and,  if  a  finger  can  be  intro- 
duced, the  size  and  situation  of  the  fetus  and  of  the  chorion 
frondosum  should  be  determined  ;  the  left  hand  should  depress 
the  fundus  uteri  through  the  abdominal  wall  during  this  exam- 
ination. 

The  curet-forceps  should  next  be  introduced,  in  order  to  pull 
out  the  embryo  entire  or  piecemeal.  The  finger  should  then  be 
introduced,  in  order  to  separate  the  entire  ovum  and  decidua 
reflexa  from  the  uterus,  the  latter  being  well  pushed  down  from 
above.  If  this  is  successful,  the  tissue  is  remo\'ed  in  pieces  by  the 
curet-forceps.  If  the  finger  cannot  be  used  in  this  way,  separa- 
tion and  removal  may  be  carried  out  by  the  instrument  alone. 
During  the  procedure  it  is  advisable  to  douche  the  uterus  as 
much  as  possible  with  hot  water  (iio°  F.),  in  order  to  stimulate 
the  uterus  to  contraction,  so  as  to  reduce  its  area  and  make  its 
wall  more  easily  felt,  and  at  the  same  time  check  hemorrhage. 
The  whole  wall  should  be  systematically  scraped  by  the  forceps  ; 
a  curet  is  rarely  needed.  If  one  is  employed,  it  should  have  a 
blunt  or  a  well-rounded  end,  so  that  there  should  be  little  risk  of 
perforating  the  uterine  wall.  After  the  uterus  is  emptied  a  strip 
of  aseptic  or  antiseptic  gauze  should  be  packed  in  the  cavity  for 
twenty-four  hours,  being  tied  to  another  piece  placed  in  the  vagina. 
Ergot  is  rarely  necessary  after  this  operation,  for  the  purpose  of 
favoring  uterine  contraction. 

{8)  III  Two  Stages. — In  the  second  and  third  months  it  may 
rarely  happen  that  the  cervix  is  so  hard  as  to  be  undilatable  to 
such  an  extent  that  the  uterus  can  safely  be  emptied.  In  such  a 
case  dilatation  should  be  carried  out  as  far  as  possible  without 
rupturing  the  membranes,  and  gauze  should  be  packed  inside 
the  OS  internum  and  in  the  cervical  canal,  or  a  small  rubber  bag 
should  be  inserted,  an  antiseptic  tampon  being  placed  in  the 
vagina.  In  twenty-four  hours,  if  the  uterus  has  not  emptied 
itself,  the  patient  should  be  anesthetized,  the  gauze  removed,  the 
cervix  further  dilated,  and  the  uterine  contents  removed  with 
curet-forceps. 

II.  From  the  Third  to  the  Sixth  Month  of  Pregnancy. — {a)  In 
One  Sitting. — In  some  cases  the  uterus  may  be  emptied  in  the 
manner  already  described.     The  fetus  is  most  easily  delivered  by 


PREMATURE   LABOR.  663 

the  breech.  When  this  part  does  not  present,  turning  should  be 
carried  out  by  bimanual  manipulations,  in  order  that  the  legs  may 
be  seized  and  pulled  down.  When  the  head  is  too  large  to  pass 
through  the  dilated  cervical  canal,  it  should  be  perforated  through 
the  occiput,  in  order  that  its  collapse  may  follow.  The  operation 
is  usually  more  difficult  than  in  the  early  months  of  gestation. 

{U)  In  Two  Stages. — When  the  cervical  tissue  is  very  firm,  it 
is  advisable  to  dilate  the  canal  as  much  as  possible  without  pro- 
ducing laceration.  A  rubber  bag  is  then  introduced  so  as  to  lie 
partly  in  the  cervix  and  partly  above  it,  under  the  membranes, 
distended  with  sterile  water  or  normal  salt  solution.  If  a  strong 
rubber  bag  is  not  obtainable,  sterile  or  antiseptic  gauze — i.  e\, 
chinosol,  may  be  packed  in  the  uterus  below  the  membranes,  in 
the  cervical  canal,  and  in  the  upper  part  of  the  vagina.  The 
patient  is  then  sent  to  bed.  Uterine  contractions  develop  and 
may  lead  to  the  expulsion  of  the  entire  contents  of  the  uterus. 
If  this  has  not  occurred  within  twenty-four  hours,  she  should  be 
anesthetized,  the  cervix  further  dilated,  and  the  ovum  removed 
with  fingers  and  instruments. 

(r)  Occasionally  it  is  inadvisable,  on  account  of  the  patient's 
condition,  to  perform  the  abortion  in  two  stages,  even  when  the 
cervix  is  very  firm  and  dilates  with  difficulty.  The  best  procedure 
is  one  similar  to  vaginal  Cassarean  section  as  performed  in  full- 
time  cases.  The  cervix  is  dilated  as  much  as  possible,  and  the 
vaginal  wall  incised  circularly  at  its  junction  with  the  cervix,  the 
cut  being  extended  for  half  an  inch  in  each  lateral  fornix.  The 
vaginal  vault  is  then  stripped  upward  from  the  cervix,  care  being 
taken  to  separate  the  bladder  cautiously ;  the  peritoneal  reflection 
should  be  pushed  up  and  held  by  a  retractor.  The  cervix  should 
then  be  split  anteroposteriorly,  the  incision  being  carried  into  the 
lower  segment  as  high  as  is  necessary  to  afford  room  for  manipu- 
lations. Through  the  opening  the  uterine  contents  are  removed. 
Afterward  the  divided  tissues  are  stitched  together  with  catgut 
and  a  gauze  tampon  placed  in  the  uterus. 

Premature  I^abor. — The  induction  of  premature  labor  after 
the  period  of  viability  may  be  undertaken  for  those  reasons 
already  mentioned  as  indications  for  the  performance  of  abortion, 
the  operation  being  undertaken  solely  with  regard  to  the  welfare 
of  the  mother.  Most  frequently,  however,  premature  labor  is  an 
operation  of  choice,  undertaken  with  a  view  to  the  safety  both  of 
mother  and  fetus.  For  this  purpose  it  has  been  most  frequently 
employed  in  contracted  pelves,  which  do  not  admit  of  the  safe 
delivery  of  a  living  child  at  full  time  by  the  natural  passage. 
The  increased  safety  of  Cassarean  section  has  undoubtedly  dimin- 
ished the  range  of  its  employment  in  such  cases  in  recent  years. 
In  the  practice  of  some  authorities  symphysiotomy  at  term  has 
also  somewhat   displaced  the   operation.     Habitual   death  of  the 


664 


ARTIFICIAL    INTERRUPTION  OF  PREGNANCY. 


fetus  late  in  pregnancy,  placental  disease,  and  habitual  large  size 
of  the  head  have  also  been  regarded  as  indications. 

Preliminaries. — A  consultation  is  always  advisable  when 
premature  labor  is  proposed.  The  patient  should  be  kept  in  bed 
a  few  days  before  the  operation,  the  diet  being  simple  and  the 
bowels  well  regulated.  It  is  advisable  to  secure  the  services  of  a 
wet-nurse,  and  an  incubator  should  be  provided  for  the  child. 

Methods  of  Inducing  Labor. — The  various  procedures  used  to 
bring  about  emptying  of  the  uterus  in  early  pregnancy  have  also 
been  employed  in  the  late  months.  The  following  are  the  most 
serviceable : 

I.  In  Cases  where  there  is  no  Urgency. — The  woman  should  be 


Fig.  270. — Champetier  de  Ribes  bag  lying  in  position  in  cervix  and  lower  uterine  seg- 
ment (Bumm). 


placed  in  the  lithotomy  posture,  anesthetized,  and  prepared  as  for 
a  surgical  operation.  The  cervix  should  be  dilated  with  graduated 
metal  dilators  as  far  as  possible  without  laceration  of  its  tissues. 
A  finger  should  be  introduced  to  separate  the  membranes  a  short 
distance  above  the  os  internum.  A  conical  rubber  bag,  of  the 
type  devised  by  Champetier  de  Ribes  or  Boissard,  is  then  intro- 
duced by  means  of  forceps  so  as  to  lie  below  the  membranes  in 
the  lower  uterine  segment,  its  lower  end  projecting  into  the  cervix. 


PREMATURE   LABOR. 


665 


Through  a  tube  attached  to  this  end  the  bag  is  filled  with  sterile 
water  or  normal  saline  solution,  the  tube  being  closed,  so  that  the 
water  may  be  retained.  The  patient  is  then  sent  to  bed.  The 
bag  acts  as  a  stimulant  to  the  uterus.  Its  conical  shape  prevents 
it  from  being  expelled  from  the  uterus  too  soon,  and  makes  it 
valuable  as  a  dilator.  It  is  indeed  a  fluid  wedge,  like  the  normal 
bag  of  membranes.  Labor  is  usually  completed  within  ten  to 
twenty  hours.  The  patient  should  be  attended  as  in  a  full-time 
labor.  After  pains  have  been  in  progress  four  or  five  hours  a 
vaginal  examination  should  be  made.  If  the  dilatation  is  well 
advanced,  the  bag  should  be  removed,  nature  being  allowed  to 
complete  the  process.  If  it  is  not  well  advanced,  the  case  may  be 
left  for  a  few  hours  longer,  or  if  the  patient  is  not  in  good  condi- 
tion, traction  on  the  bag  may  be  made,  especially  during  the  pains, 
to  assist  in  dilatation. 

An  objection  has  been  made  to  the  Champetier  de  Ribes  bag 
that  it  may  displace  the  presenting  part  of  the  fetus — /'.  e.,  it  may 
change  a  head  to  a  transverse  presentation.  This  is  a  just  criticism, 
but  the  objection  is  unimportant  if  the  physician  watch  the  case 
carefully.  On  removing  the  bag  from  the  cervix,  examination 
should  always  be  made  to  determine  the  presentation.     If  there 


Fig.  271. — Barnes's  bag. 

has  been  a  displacement,  it  should  be  rectified  by  bimanual  ma- 
nipulations without  rupturing  the  membranes.  Labor  may  there- 
after be  completed  by  the  natural  powers,  or  it  may  be  advisable 
to  deliver  by  forceps  or  turning,  when  dilatation  is  completed. 
The  habit  of  introducing  a  bag  and  allowing  it  to  be  born  with  the 
fetus,  without  making  an  examination,  is  to  be  condemned,  be- 
cause if  the  presentation  has  been  altered,  serious  complications 


Fig.  272. — McLean's  model  of  Barnes's  bag. 

may  arise  which  may  endanger  the  life  of  the  fetus.  The  Boissard 
type  of  bag  has  a  concave  top,  and  is  less  likely  to  cause  malpres- 
entation  than  that  of  Champetier  de  Ribes.  Instead  of  these 
bags,  the  older  forms  devised  by  Barnes  may  be  used ;  the  cervix 
is  dilated  with  metal  dilators  sufficiently  to  allow  the  entrance  of 
one   of  these  fiddle-shaped   bags,  which  is   then  distended  with 


666 


ARTIFICIAL    INTERRUPTION   OF  PREGNANCY. 


sterile  fluid.  Labor  pains  may  undoubtedly  be  induced  by  its 
presence,  but  it  is  not  so  good  a  stimulus  as  the  bag  that  rests 
mainly  above  the  cervix.  Moreover,  it  is  soon  expelled  into  the 
vagina  after  dilatation  proceeds.  Schauta  and  Tarnier  have  also 
recommended  the  introduction  of  bags  internal  to  the  cervix,  but 
these  forms  are  not  conical  in  shape,  and,  therefore,  lack  the  ad- 
vantages of  the  de  Ribes  and  Boissard  types. 

Of  other   methods   employed,   only   that   of  Krause  need  be 
recommended,  though  it  is  inferior  to  that   described  above.     It 

consists  in  the  introduction  into  the 
uterus,  external  to  the  membranes, 
of  a  flexible  bougie,  a  gauze  tampon 
being  placed  in  the  vagina,  against 
the  cervix,  to  keep  the  bougie  in 
place.  This  procedure  may  act  satis- 
factorily, but  it  is  often  very  slow, 
and  the  cervix  may  not  be  dilated 
until  many  hours  have  elapsed. 
Sometimes  it  is  very  difficult  to  in- 
troduce the  bougie.  The  instrument 
should  not  be  used  unless  it  can  be 
sterilized  by  heat.  It  is  best  made 
of  solid  flexible  rubber,  which  may 
be  boiled. 

The  induction  of  labor  by  the 
vaginal  tampon  or  colpeurynter  is 
ven'  uncertain.  Evacuation  of  the 
liquor  amnii  is  to  be  condemned, 
since  it  causes  a  protracted  dry 
labor,  adds  to  the  risk  of  sepsis, 
and  almost  always  destroys  the  life 
of  the  fetus.  The  injection  of  fluids — 
i.  c,  water  and  glycerin — is  very  un- 
reliable and  not  without  risks. 

Hamilton's  method  of  separating 
the  membranes  for  a  short  distance 
above  the  cervix  is  also  very  uncer- 
tain. 

II.  /;/  Cases  zvhcre  Urgency  Ex- 
ists.— The  French  expression  accou- 
chement force  is  usually  applied  to  the  method  of  rapidly  and 
forcibly  dilating  the  intact  or  partially  dilated  cervix  in  ad- 
vanced pregnancy  or  at  term  for  the  purpose  of  removing  the 
uterine  contents.  The  operation  may  be  very  difficult  if  the 
cervix  be  hard  and  unaltered,  the  risk  of  extensive  laceration  and 
hemorrhage  being  considerable.     When  the  cervix  is  soft  and  the 


Fig.  273 . — Boissard's  rubber  bag : 
a,  Empty ;  h,  distended.  In  the 
latter  condition,  as  it  lies  in  the 
cervix  and  lower  uterine  segment, 
the  upper  surface  is  concave  (Tar- 
nier and  Budin). 


PREMATURE   LABOR. 


667 


canal  partially  obliterated  the  procedure  is  frequently  easy.  It  is 
more  difficult  in  primiparae  than  in  multiparae. 

hidicatioiis. — It  is  most  frequently  performed  in  eclampsia  ; 
sometimes  it  is  necessary  in  antepartum  hemorrhage,  in  heart, 
lung,  and  kidney  lesions,  and  in  other  serious  conditions  of  the 
mother  in  which  the  continuance  of  gestation  may  endanger  her 
health. 

Methods. — Occasionally  a  soft  cervix  somewhat  dilated  may 
be  rapidly  opened  by  Barnes's  bags  or  by  one  of  the  Champetier 
de  Ribes  type ;  when  the  latter  is  used,  it  should  be  pulled  down- 


FlG.  274. — Method  of  performing  rapid  manual  dilatation  of  the  os  uteri :  i,  Posi- 
tion of  fingers  in  the  beginning  of  manual  or  digital  dilatation  of  the  cervix  uteri,  first 
position;  2,  showing  limit  of  dilatation  in  the  first  position;  3,  second  position;  4, 
showing  limit  of  dilatation  in  the  second  position  ;  5,  third  position  ;  6,  limit  of  dilata- 
tion in  the  third  position  ;  7,  fourth  position  ;  8,  limit  of  dilatation  in  the  fourth  position  ; 
9,  fifth  position  ;  10,  sixth  position  (Harris). 


ward  steadily  and  with  intermissions.  Recently,  however,  manual 
dilatation  has  to  a  great  extent  displaced  the  use  of  bags  in  such 
cases ;  the  fingers  of  one  or  both  hands  may  be  used.  The 
method  described  by  Philander  Harris  is  very  serviceable.  A 
finger  is  first  introduced  into  the  cervical  canal,  then  a  finger  and 
thumb,  then  two  fingers,  and  so  on  until  the  cervix  is  gradually 
stretched  to  the  desired  size.    In  cases  in  which  there  is  no  dilata- 


668 


ARTIFICIAL   INTERRUPTION  OF  PREGNANCY. 


tion  whatever,  several  graduated  steel  dilators  may  be  used,  in 
order  to  allow  a  finger  and  thumb  to  be  introduced.  If  the  hand 
becomes  tired  during  the  maneuver,  the  fingers  of  both   hands 


Fig.  275. — Champetier  de  Ribes  bag:  A,  Inflated;  B,  folded  for  introduction  into  the 

uterus. 

may  be   used  for  a  time  to  stretch  the  cervix  in  opposite  direc- 
tions. 

These  procedures  should  be  carried  out,  if  possible,  without 
rupturing  the  membranes.     Rubber  gloves  should  be  worn  and 

the  strictest  technic  observed. 

The  patient  should  be  anes- 
thetized and  placed  in  the  lith- 
otomy posture.  In  cases  in 
which  there  is  no  abnormal 
rigidity  of  the  cervix,  complete 
dilatation  may  be  obtained  in 
twenty  to  sixty  minutes.  In 
cases  of  very  rigid  cervix  these 
methods  should  not  be  em- 
plo\-ed,  since  dilatation  cannot 
be  accomplished  unless  unwar- 
rantable force  is  used,  and  this 
may  lead  to  dangerous  lacera- 
tion of  the  uterus. 

In  the  condition  of  hard 
and  undilatable  cervix  various 
procedures  have  been  recom- 
mended. Diihrssen  has  re- 
cently urged  the  value  of 
multiple  cervical  incisions,  pre- 
viously suggested  by  Braun, 
Skutsch,  Baudelocque,  and 
others.  Experience  has,  however,  shown  that  this  method  is  uncer- 
tain, and  that  it  is  associated  with  grave  risk  from  bad  laceration 
and  hemorrhage  ;  it  is  not  to  be  employed  except  as  a  last  resort. 
Effacement  of  the  cervix  is  an  indispensable  prerequisite  to  the 


Fig.  276. — Artificial  dilatation  of  cervix 
with  fingers  of  both  hands  (Tarnier  and 
Budin). 


EXTERNAL    VERSION.  669 

use  of  incisions,  and  immediate  delivery  should  follow  them.  Of 
greater  value  in  such  cases  is  the  operation  of  vaginal  Caesarean 
section  recommended  by  Acconci  and  Duhrssen.  (See  chapter  on 
Caesarean  Section.) 

Bossi's  four-bladed  expanding  steel  dilator  has  recently  been 
recommended,  but  it  has  not  been  sufficiently  tested  to  establish 
its  value.  Some  operators,  while  admitting  that  it  may  occasion- 
ally be  serviceable,  state  that  its  routine  use  is  likely  to  lead  to 
very  serious  results  from  laceration  and  hemorrhage. 


CHAPTER    II. 

VERSION  OR  TURNING. 

Version  is  a  manipulation  carried  out  for  the  purpose  of 
changing  the  presentation  of  the  fetus  for  one  considered  to  be 
more  favorable  for  delivery.  In  some  cases  the  vertex  may  be 
made  to  present ;  in  others,  the  breech.  Version  may,  therefore, 
be  considered  under  the  two  headings  : 

1.  Cephalic — causing  vertex  presentation. 

2.  Pelvic — causing  breech  presentation. 

Of  these,  the  latter  is  by  far  the  more  frequently  employed  in 
practice,  though  in  head  presentations  it  has  become  less  common 
than  in  former  years,  owing  to  the  increasing  use  of  axis-traction 
forceps.  Since  this  instrument  has  been  introduced  in  the  treat- 
ment of  labor  delayed  by  flattening  of  the  pelvis,  the  scope  of 
the  operation  is  likely  to  be  diminished  still  further. 

Version  may  be  performed  by  external,  internal,  and  by  com- 
bined external  and  internal  manipulations. 

External  Version. — Turning  of  the  fetus  by  manipulations 
carried  out  through  the  abdominal  wall  is  occasionally  performed, 
most  frequently  for  the  purpose  of  bringing  the  head  into  relation 
with  the  inlet  of  the  pelvis.  It  is  chiefly  used  in  cases  of  transverse 
presentation  discovered  before  or  early  in  labor.  Some  authorities 
have  advised  its  employment  for  the  purpose  of  changing  a  pelvic 
to  a  head  presentation  ;  this  has  been  opposed  by  others,  and  for 
a  good  reason — viz.,  the  impossibility  of  being  certain  of  bringing 
about  a  favorable  position  of  the  head  after  version.  In  face  or 
brow  presentations  diagnosed  early  in  labor,  external  manipula- 
tions have  been  used  to  bring  about  a  vertex  presentation.  (See 
p.  499.) 

The  operation  of  external  version  is  rarely  easily  performed. 
It  should  not  be  attempted  in  cases  of  multiple  pregnancy,  when 
the  presenting  part  is  engaged  in  the  pelvis  ;  after  rupture  of  the 


670  .  VERSION  OR    TURNING. 

membranes,  when  the  fetus  is  dead;  when,  after  labor  has  started, 
there  is  abnormal  stretching  of  the  lower  uterine  segment,  or 
when  a  uterine  or  other  tumor  complicates  pregnancy.  It  is  very- 
difficult  in  primiparse,  in  fat  women,  and  sometimes  when  the 
uterus  is  much  distended  with  liquor  amnii.  If  the  cord  be  short 
or  wound  around  the  neck,  there  may  be  risk  to  the  fetus.  It  is 
most  easily  carried  out  in  a  multipara  a  week  or  two  before  the 
eighth  month  of  pregnancy  when  the  fetus  is  not  too  large. 

In  carrying  out  the  operation  the  woman  should  be  placed  on 
her  back,  the  head  and  thorax  being  slightly  raised,  and  the  thighs 
drawn  up.  The  rectum  and  bladder  should  be  empty.  The 
hands  of  the  operator  should  be  warm.  The  fetal  poles  are 
moved  by  a  combination  of  taps  and  pushes,  the  normal  flexion 
being  preserved.  If  the  patient  resists  in  any  way,  anesthesia 
should  be  employed.  During  a  pain  manipulations  must  cease, 
the  hands  endeavoring  to  hold  the  fetus,  so  that  the  progress 
already  made  may  not  be  lost.  In  the  case  of  a  transverse  pres- 
entation one  hand  is  placed  on  the  head,  the  other  on  the  breech, 
the  fetus  being  moved  according  to  whether  a  head  or  breech 
presentation  is  desired.  \Mien  a  face  or  brow  presents,  the  head 
should  be  grasped  in  both  hands  and  an  effort  made  to  flex  it  so 
as  to  get  a  vertex  presentation.  (See  pp.  495,  501.)  The  whole 
fetus  should  be  raised  toward  the  fundus  in  carrying  out  this 
manipulation. 

After  version  the  patient  may  be  kept  quiet ;  a  pad  may  be 
applied  on  each  side  of  the  uterus  and  a  binder  placed  around  the 
abdomen,  in  order  to  preserve  the  fetus  in  the  new  position. 

Internal  Version. — Turning  of  the  fetus  by  intra-uterine 
manipulations  has  been  practised  for  many  centuries.  In  the 
earliest  times  the  head  was  brought  to  the  pelvic  brim.  Celsus 
is  believed   to   ha\'e   first  recommended  the  method  of  brincrinp- 

o       o 

about  a  pelvic  presentation  when  the  fetus  was  dead.  Soranus, 
of  Ephesus,  first  employed  the  maneuver  to  obtain  a  living  fetus. 
Pelvic  version  was  not  much  practised  until  Ambrose  Pare  rein- 
troduced the  operation  in  the  sixteenth  century. 

At  the  present  time  cephalic  version  is  rarely  attempted  by 
internal  manipulations.  It  has  been  especially  recommended  in 
cases  of  shoulder  presentation,  soon  after  rupture  of  the  mem- 
branes following  full  dilatation  of  the  cervix.  It  should  not,, 
however,  be  carried  out  if  the  cord  or  an  extremity  be  prolapsed. 
The  shoulder  is  grasped  by  the  hand  and  pushed  up,  assisted  by 
manipulations  of  the  other  hand  through  the  abdominal  wall,  so 
that  the  head  descends  toward  the  brim.  The  operation  is  occa- 
sionally successful ;  it  should  be  tried  only  under  anesthesia  and 
should  be  followed  by  forceps  delivery,  the  head  being  held  at  the 
brim  by  an  assistant  pressing  through  the  abdominal  wall. 

Of  greater  importance  is  pelvic  version,  or,  as  it  is  moregener- 


PELVIC   OR   POD  A  Lie    VERSION.  67 1 

ally  termed,  podalic,  since  the  feet  are  usually  grasped  in  turning 
the  fetus. 

Pelvic  or  Podalic  Version. — This  operation  may  be  carried 
out  in  the  following  circumstances  :  Transverse  presentations  in 
certain  conditions ;  prolapsus  funis  in  certain  conditions ;  brow 
and  face  cases  in  certain  conditions  ;  prolapse  of  one  or  both  arms 
or  of  a  lower  extremity  ;  placenta  previa  and  accidental  hemor- 
rhage ;  threatened  death  in  eclampsia  or  other  complications  ; 
and  flat  pelves. 

In  none  of  these  conditions  is  the  indication  always  absolute. 
The  operation  may  be  frequently  chosen  as  an  alternative  pro- 
cedure. 

Conditions  Favorable  to  the  Performance  of  Podalic  Ver= 
sion. — The  pelvis  must  not  be  too  contracted.  The  operation  should 


Fig.  277. — First  step  of  bipolar  podalic  version  :  two  fingers  within  the  cervix  lift  the 
head  toward  the  iliac  fossa,  while  the  breech  is  crowded  over  toward  the  other  ilium. 

not  be  carried  out  in  a  flat  pelvis  whose  conjugate  measures  less 
than  8  cm.,  the  fetal  head  being  of  normal  size.  The  cervix  must 
be  fully  dilated  or  capable  of  being  dilated.  The  hand  should 
never  be  forcibly  pushed  into  the  uterus.  The  presenting  part  of 
the  fetus  should  not  be  firmly  impacted  in  the  brim,  but  should 
be  mobile  above  it. 

The  uterus  must  not  be  firmly  retracted  down  on  the  fetus, 
lest  in  the  efforts  to  perform  version  the  lower  uterine  segment  be 
ruptured.  The  most  favorable  period  is  when  the  cervix  is  fully 
dilated  and  the   membranes  are  ruptured  by  the  operator.     After 


6j2 


VERSION  OR    TURNING. 


rupture  version  may  also  be  performed,  but  the  longer  the  pro- 
cedure is  delayed,  the  greater  the  difficulty  and  risk,  because  of 
the  retraction  of  the  uterus.  It  is  impossible  to  define  a  limit  for 
the  safe  performance  of  version.  It  might  be  feasible  in  one  case 
four  hours  after  the  escape  of  the  amniotic  fluid,  and  dangerous  in 
another  one  hour  afterward.  In  some  cases  the  uterus  relaxes 
greatly  under  anesthesia  ;  in  other  cases  to  a  slight  extent.  At- 
tention must  always  be  paid  to  the  level  of  the  retraction  ridge. 
The  higher  it  is  above  the  normal,  the  greater  is  the  danger,  owing 
to  the  stretching  of  the  lower  uterine  segment.  If  the  ridge  can 
be  felt  two  or  more  inches  above  the  pubes,  there  is  great  risk  in 
turning;  it  should  not  be  firmly  applied  to  the  fetus. 

Operation. — After  the  relations  of  the  fetus  have  been  deter- 
mined by  abdominal  examination,  the  bladder  and  rectum  having 


Fig.  278. — Direct  method  of  seizing 
•a  foot  in  version  for  transverse  presen- 
tations. 


Fig.  279. — Direct  method  of  seizing 
a  foot  in  version  for  transverse  presen- 
tations. 


been  emptied,  the  patient  should  be  placed  in  the  lithotomy  posi- 
tion and  anesthetized.  In  England  the  lateral  posture  is  commonly 
adopted.  Ritgen  and  others  have  recommended  the  genupectoral 
posture.  The  genitalia  should  be  shaved  and  cleansed  as  if  a 
surgical  operation  were  in  prospect.  The  strictest  asepsis  should 
be  observed  by  the  operator,  and  he  should  give  special  attention 
to  the  cleansing  of  the  whole  forearm  and  lower  part  of  the  upper 
arm.  The  author  recommends  the  use  of  rubber  gloves  and  long 
gauntlets,  or  of  a  sterile  linen  arm  cover  that  the  glove  fits  at  the 
wrist.  A  faulty  technic  is  apt  to  lead  to  infection  in  all  cases  in 
which  the  hand  is  introduced  into  the  genital  tract.  It  is  impor- 
tant to  decide  which  hand  should  be  introduced  into  the  uterus. 


PELVIC   OR    POD  A  Lie    VERSION. 


673 


That  one  should  be  chosen  which  can  carry  out  the  manipulations 
most  easily  and  satisfactorily.  In  vertex,  face,  and  brow  presen- 
tations, when  the  occiput  looks  to  the  left,  the  left  hand  should 
be  used ;  when  it  looks  to  the  right,  the  right  hand.  In  trans- 
verse presentations,  when  the  back  is  anterior  and  the  head  on 
the  left  side,  the  right  hand  should  be  used ;  when  the  head  is  on 
the  right  side,  the  left  hand.  In  dorsoposterior  positions  the  left 
hand  should  be  used  when  the  head  is  on  the  left  side  ;  the  right 
hand  when  it  is  on  the  right  side.  Version  in  these  positions  is 
more  easily  carried  out  if  the 
patient  be  placed  on  her  side  ; 
in  a  left  scapuloposterior,  on 
the  right  side  ;  in  a  right,  on 
the  left  side. 

The  back  of  the  chosen 
hand  and  arm  should  be  lu- 
bricated with  sterile  vaselin^ 
and  the  fingers  arranged  in 
the  shape  of  a  cone,  which  is 
gradually  introduced  into  the 
vagina  and  passed  through 
the  cervix,  being  slightly  ro- 
tated from  one  side  to  the 
other,  the  other  hand  steady- 
ing the  fundus  of  the  uterus 
through  the  abdominal  wall, 
which  is  covered  with  a  sterile 
sheet.  If  the  cervix  needs  to 
be  somewhat  dilated,  the  mem- 
branes should  be  preserved  if 
still  intact.  If  the  membranes 
are  intact,  they  should  be  rup- 
tured, and  the  hand  advanced 
so  that  its  palmar  aspect  is 
applied  to  the  fetus-  and  its 
dorsal  surface  next  the  uterine 
wall.  It  is  important  that  as 
much  fluid  as  possible  be  re- 
tained, in   order    to    facilitate 

manipulations.  Its  escape  may  be  considerably  prevented  by 
the  plugging  of  the  vagina  by  the  forearm.  It  has  been  rec- 
ommended by  some  authors  that  an  effort  be  made  to  preserve 
the  bag  of  membranes  as  long  as  possible,  and  that  the  hand 
should  be  passed  up  between  the  membranes  and  uterine  wall  as 
far  as  possible  before  they  are   ruptured.     This  procedure  is  in- 

^  If  rubV;er  gloves  are  worn,  vaselin  should  not  be  used,  sterile  water  or  creolin 
solution  ( 1  :  lOO)  sufficing  as  a  lubricator. 


y\^ 


\ 


Fig.  280. — Traction  on  near  leg  is  made 
diagonally  across  mother's  pelvis  to  pull 
child's  breech  into  the  inlet. 


674 


VERSION   OR    TURNING. 


advisable  ;  it  is  not  easily  carried  out  and  is  apt  to  cause  a  sepa- 
ration of  the  placenta. 

If  the  membranes  have  already  ruptured,  the  hand  is  passed 
directly  into  the  amniotic  cavity.  If  any  pressure  is  used,  it  should 
be  applied  to  the  fetus  rather  than  to  the  uterine  wall.  If  a 
uterine  contraction  occurs,  the  fingers  should  lie  loosely  on  the 
fetus,  the  hand  ceasing  to  advance  until  the  pain  passes  off  If 
the  head  is  in  the  way,  it  may  be  pushed  toward  the  side  on  which 
the  occiput  lies.    When  the  lower  limbs  are  felt,  the  cord  must  be 


Fig.  281. — Breech  enters  pelvis  with  trac- 
tion in  right  direction. 


Fig.  282. — New  seizure  on  thigh  :  the 
leg  on  which  traction  is  made  being  ante- 
rior leg  in  pelvis. 


disengaged  from  them  before  traction  is  made.  There  is  a  differ- 
ence of  opinion  as  to  whether  one  or  both  feet  should  be  grasped. 
In  head  presentations  it  is  immaterial,  except  when  there  is  doubt 
as  to  the  completeness  of  dilatation  of  the  cervix,  and  it  is  intended, 
after  version,  to  leave  the  delivery  to  nature.  In  such  a  case  one 
leg  should  be  pulled  down,  the  other  being  allowed  to  lie  against 
the  abdomen,  in  order  that  better  dilatation  of  the  cervix  may 
take  place  before  the  head  passes  through  it.     A  single  foot  should 


PELVIC   OR   PODALIC    VERSION.  675 

be  held  at  the  ankle,  between  the  thumb  and  fingers,  or  the  whole 
leg  may  be  grasped. 

Some  authors  believe  it  to  be  advantageous  in  transverse  cases 
to  catch  one  foot,  and  there  has  been  much  discussion  as  to  whether 
the  farther  or  the  nearer  foot  should  be  grasped.  Hart's  advice  is 
valuable — viz.,  to  grasp  the  leg  that  will  maintain  a  dorso-anterior 
position  or  will  change  a  dorsoposterior  into  a  dorso-anterior — i.e., 
take  the  farther  limb  for  dorsoposterior  cases,  the  nearer  for 
dorso-anterior  cases.  Hart  points  out,  however,  that  when  in  dorso- 
anterior  cases  the  breech  is  in  the  fundus,  traction  on  the  nearer 
leg  may  convert  it  into  a  dorsoposterior ;  and  when  the  breech  is 
nearer  the  os  in  dorsoposterior  cases,  traction  on  the  farther  leg 
may  not  alter  the  posterior  position  of  the  back  after  version, 
owing  to  the  necessary  want  of  obliquity  in  the  pull.  In  urgent 
cases  the  first  foot  obtainable  may  be  grasped. 

Some  authorities  recommend  that  a  knee  should  be  caught 
by  a  finger  placed  in  the  bend,  instead  of  a  foot.  The  former  can 
be  grasped  more  firmly  than  the  latter.  If  there  is  sometimes 
doubt  as  to  whether  an  upper  or  lower  limb  is  grasped,  the  ex- 
tremity should  be  felt.  The  wrist  is  more  movable  than  the  ankle  ; 
in  the  foot  there  is  a  projecting  os  calcis  ;  the  fingers  are  longer 
than  the  toes,  the  sole  than  the  palm  ;  and  the  arrangement  of  the 
thumb  is  characteristic.  The  foot  or  feet  are  next  drawn  toward 
the  cervix,  the  fetus  being  thereby  flexed.  The  external  hand 
may  greatly  assist  the  movement  of  the  fetus  by  manipulating  the 
head  toward  the  fundus. 

As  the  knee  or  knees  reach  the  vulva,  the  vertex  of  the  head 
usually  lies  at  the  fundus.  The  rest  of  the  delivery  may  be  left 
to  nature  or  may  be  assisted.  If  the  cervix  be  not  well  dilated,  it 
is  always  dangerous  to  the  life  or  limbs  of  the  fetus  to  hasten  de- 
livery; moreover,  there  is  risk  of  injuring  the  cervix.  When 
urgency  is  needed  on  account  of  fetal  or  maternal  complications 
— i.  e.,  feeble  fetal  circulation,  prolapse  of  the  cord,  eclampsia, 
hemorrhage,  etc. — the  fetus  should  be  extracted  artificially,  as  in 
the  manner  described  in  breech  cases.  (See  p.  507.)  Extraction 
must  always  be  accompanied  by  external  pressure  of  the  fundus 
against  the  fetal  head,  and  must  not  be  too  rapidly  performed, 
because  of  the  risk  of  upward  displacement  of  the  arms,  extension 
of  the  head,  uterine  rupture,  or  inertia. 

Difficulties  in  Version. — If  the  woman  be  not  anesthetized 
or  only  partly,  her  restlessness  may  hinder  the  operator.  The 
vulvar  orifice  may  be  small  and  may  prevent  the  easy  passage 
upward  of  the  hand  ;  in  such  a  condition  it  should  be  carefully 
dilated.  The  vagina  may  also  be  too  small  to  permit  easy  manipu- 
lations. Reference  has  already  been  made  to  an  undilated  cervix. 
When  the  soft  passages  are  diminished  by  cicatrices,  congenital 
atresia,  new  growths  and  other  swellings,  turning  may  sometimes 


6^6  .  VERSION  OR    TURNING. 

be  absolutely  contraindicated.  Uterine  contractions  interfere  with 
the  passage  of  the  hand.  Sometimes  a  tetanic  condition  is  present, 
making  it  impossible  to  perform  version  ;  this  is  especially  notice- 
able when  ergot  has  been  administered.  In  some  cases  the  re- 
traction ridge  is  tightly  applied  to  the  fetus. 

In  shoulder  presentations  an  arm  may  be  prolapsed.  When 
this  is  not  impacted  and  version  may  be  carried  out,  the  manipu- 
lations are  not  necessarily  complicated.  Some  authorities  advise 
replacing  the  hand  in  the  uterus.  This  is  not  necessary,  however ; 
it  is  better  to  tie  a  piece  of  sterile  tape  around  the  wrist  and  to 
carry  out  version  as  described.  The  arm  ma}"  be  drawn  up  some- 
what, but  it  cannot  be  extended  above  the  head.  Impaction  of  the 
fetus  in  the  brim  renders  version  veiy  difficult  and  dangerous. 
Under  anesthesia  it  should  be  attempted  only  when  impaction  is 
slight  and  early.  In  these  cases  it  is  ahvays  advisable  to  try  the 
effect  of  the  elevated  lithotomy  position.  This  can  be  obtained 
best  on  a  Boldt  table  in  a  hospital,  the  patient  being  supported  by 
shoulder  supports.  This  position  is  preferable  to  the  genupectoral 
position,  since  assistants  are  not  needed  to  support  the  woman  ; 
neither  is  there  unusual  trouble  with  the  anesthetic.  If  the  re- 
traction ridge  be  high  or  firmly  applied  to  the  fetus,  and  if 
marked  relaxation  does  not  take  place  under  chloroform,  version 
should  not  be  made. 

Sometimes,  when  the  fetus  is  partly  turned,  it  sticks,  and  ex- 
ternal manipulations  may  fail  to  complete  the  maneuver.  In  such 
a  case  it  is  sometimes  advisable  to  attach  a  sterile  band  to  the  lower 
leg,  in  order  that  traction  may  be  made  on  it,  while  a  hand  is  used 
inside  the  uterus  to  push  up  the  head.  When  the  fetus  is  turned 
by  the  posterior  foot,  the  anterior  buttock  ma}-  catch  on  the  pubes. 
To  overcome  this  difficult}'  traction  should  be  made  more  in  a 
posterior  direction.  Sometimes  it  is  necessar}-  to  push  the  hip 
away  from  the  pubes  with  a  hand.  The  complications  and  diffi- 
culties that  occur  after  the  fetus  is  turned  are  considered  in  the 
chapter  dealing  with  breech  cases. 

Dangers  in  Internal  Version. — The  maternal  risks — /.  c, 
rupture  of  soft  parts,  hemorrhage,  inertia  uteri,  etc. — have  already 
been  noted.  The  fetus  is  also  greatly  endangered.  Compression 
of  the  cord  ma}'  cause  asph}'xia.  Fractures  of  bones,  separation 
of  epiph}^ses,  and  dislocations  are  easily  produced,  and  may  be 
found  in  limbs,  trunk,  or  head.  A  lower  limb  ma}^  even  be  torn 
away.  Injuries  of  nerves,  leading  to  paralysis,  ma}- be  produced. 
Blood-extrav^asations  are  sometimes  produced  in  or  between  the 
thoracic  and  abdominal  viscera. 

Bipolar  or  Combined  Internal  and  External  Version. 
— This  method,  often  named  after  Braxton  Hicks,  consists  in  the 
application  of  the  hands  to  opposite  parts  of  the  fetus,  one  being 
placed  on  the  abdomen  and  one  or  two  fingers  of  the  other  being 


COMBINED   INTERNAL   AND   EXTERNAL    VERSION.      677 

introduced  into  the  cervix,  the  fetus  being  moved  in  the  direction 
required.  The  internal  fingers  do  not  pass  above  the  lower 
surface  of  the  presenting  part.  This  method  has  the  advantage 
that  it  may  be  used  when  the  membranes  are  unruptured  and 
when  the  cervical  canal  will  admit  only  two  fingers.  There  is  less 
risk,  therefore,  of  rupturing  the  uterus,  of  detaching  the  placenta, 
of  compressing  the  cord,  and  of  introducing  infection  than  when 
the  whole  hand  is  passed  into  the  uterus  to  turn  the  fetus. 

Cephalic  or  pelvic  version  may  be  performed  by  this  method. 
The  latter  is  most  common  ;  it  may  be  employed  in  brow,  face, 
and  transverse  cases  and  in  placenta  prsevia.  In  the  latter  con- 
dition it  is  of  the  greatest  value. 

Operation. — The  patient  is  placed  in  the  lithotomy  posture  and 


*?I«i., 


Fig.  283. — Bipolar  version  :  the  shoul- 
der and  arm  are  pushed  along  ;  the  breech 
is  pushed  downward. 


Fig.  284. — Bipolar  version  :  the  knee 
is  almost  within  reach  ;  the  head  is  pressed 
upward. 


all  preparations  are  made  as  described  for  internal  version.  The 
cervix  must  be  dilated,  naturally  or  artificially,  sufficiently  to 
allow  two  fingers  of  one  hand  to  be  passed  through  the  cervical 
canal  as  far  as  the  membranes.  When  the  placenta  covers  the  os, 
the  fingers  burrow  through  the  villi  until  they  rest  against  the 
chorionic  membrane  that  lies  external  to  the  amnion.  These 
fingers  are  then  used  to  jerk  or  push  the  presenting  part  toward 
one  side,  while  the  abdominal  hand  moves  the  opposite  pole  of 
the  fetus  in  the  opposite  direction,  the  manipulations  being  made 
between  the  pains.  In  rotating  the  fetus  its  attitude  of  flexion 
should   be  preserved,  if  possible.     When  the  head  is  brought  to 


6/8  .,  THE   FORCEPS. 

the  brim,  it  should  be  correctly  placed  by  the  fingers.  Many 
advise  that  at  this  stage  the  membranes  should  be  ruptured,  to 
ensure  that  the  head  will  not  move  away  from  the  inlet,  being 
prevented  by  the  uterine  retraction  that  follows  escape  of  the 
liquor  amnii.  Others  recommend  holding  the  fetus  in  place  by 
hands  or  by  two  lateral  compresses  applied  to  the  abdomen,  dila- 
tation of  the  cervix  and  rupture  of  the  membranes  being  allowed 
to  take  place  naturally.  The  choice  of  either  of  these  methods 
must  be  made  according  to  circumstances.  As  a  rule,  the  latter 
may  be  adopted. 

In  turning  the  fetus  to  bring  the  breech  to  the  os,  the  outer 
hand  should  be  used  to  raise  the  head  as  it  begins  to  rise  above 
the  iliac  fossa.  When  the  breech  is  brought  to  the  brim,  the 
membranes  should  be  ruptured  and  a  leg  brought  well  down  into 
the  vagina,  the  case  being  then  left  to  nature,  or  artificial  dilata- 
tion of  the  cervix  may  be  employed  when  rapid  delivery  must  be 
effected.     (See  pp.  507,  554.) 


CHAPTER    III 
THE  FORCEPS. 


The  obstetric  forceps  is  an  instrument  for  holding  the  fetal 
head  (rarely  the  breech),  in  order  that  traction  may  be  exerted 
for  the  purpose  of  delivering  the  fetus. 

Historic. — There  is  abundant  evidence  that  the  forceps  was 
in  use  among  Arabian  physicians  before  the  twelfth  century, 
though  it  was  not  known  in  Europe.  The  modern  instrument 
has  been  gradually  evolved  during  the  last  three  centuries. 

After  the  massacre  of  St.  Bartholomew  in  1572,  William 
Chamberlen,  a  French  Huguenot,  fled  to  England  with  his  family 
for  safety.  Among  his  children  were  two  sons,  each  of  whom 
was  named  Peter.  They  afterward  became  physicians  in  London. 
The  elder  brother,  born  in  Paris  in  1560,  was  the  inventor  of  the 
forceps.  He  had  a  large  practice  in  London  and  attended  Queen 
Henrietta  Maria,  wife  of  Charles  I.,  when  she  miscarried  of  her 
first  child.  He  died  in  163 1,  leaving  no  children.  His  younger 
brother  Peter  had  several  sons,  one  of  whom,  named  for  his  father, 
was  eminent  as  a  physician.  He  kept  the  knowledge  of  the 
forceps  a  secret,  transmitting  it  to  his  sons,  Hugh,  Paul,  and  John, 
who  also  became  physicians.  Hugh  Chamberlen  went  to  Paris  in 
1670  in  the  hope  of  selling  the  secret  of  the  forceps.  Mauriceau 
invited  him  to  use  the  instrument  in  a  case  of  delayed  labor  due 
to  marked  pelvic  deformity.     Chamberlen  was  unsuccessful  and 


iiisroRrc.  679 

returned  to  London.  In  1672  he  published  an  English  transla- 
tion of  Mauriceau's  Midzvifcry ,  in  which  he  refers  to  the  method 
known  to  his  family  for  the  safe  delivery  of  women  in  different 
cases,  without,  however,  describing  the  nature  of  the  secret.  This 
reference  attracted  much  attention  in  the  medical  world.  In  1688 
the  same  Hugh  Chamberlen  went  to  Holland,  where  it  is  claimed 
he  sold  his  secret  to  Roonhuysen,  who  in  turn  disposed  of  it  to 
Ruysch  and  others.  The  facts  concerning  these  transactions  are 
not  accurately  known.  It  is  held  by  some  that  Chamberlen  re- 
vealed the  knowledge  of  a  single  blade  or  lever,  which  was  also 
the  invention  of  the  original  Peter  Chamberlen.  Others  hold  that 
Hugh  showed  the  forceps,  but  that  Roonhuysen  and  Ruysch 
separated  the  blades  and  used  each  as  a  lever.  Certain  it  is  that 
the  secret,  which  was  kept  by  the  Medicopharmaceutical  College 
at  Amsterdam,  and  which  all  who  desired  to  practise  midwifery 
were  required  to  purchase,  referred  to  a  single-bladed  instrument, 
for  in  1753  Visscher  and  Van  de  Poll  made  the  secret  public. 
Palfyn,  of  Ghent,  in  1720,  after  having  made  many  journeys  to 
London  to  learn  about  the  Chamberlen  instrument,  exhibited  a 
pair  of  forceps  before  the  Academy  of  Science  at   Paris.     This 


Fig.  285. — Vectis  or  lever. 

must  be  regarded  as  the  first  public  demonstration  of  the  forceps. 
Very  soon  various  patterns  of  forceps  were  introduced  to  the  pro- 
fession. The  instruments  used  by  the  Chamberlen  family  were 
only  discovered  in  18 13,  when  a  chest  stored  away  in  a  closet  was 
opened  in  the  Chamberlen  country  house,  Woodham  Mortimer 
Hall,  Essex,  where  it  had  been  for  more  than  a  century,  the  prop- 
erty having  passed  out  of  the  hands  of  the  Chamberlen  family 
in  171 5.  The  chest  contained  a  single  blade  or  lever,  with  a 
fenestrum,  and  3  forceps ;  of  the  latter,  one  consisted  of  two 
blades  jointed  by  a  riveted  pivot ;  another,  of  blades  connected  by 
a  loose  pivot,  one  blade  fitting  into  a  hole  in  the  other;  a  third, 
in  which  the  shanks  fitted  together  without  crossing,  being  held 
by  a  string  wound  around  the  shanks  and  passing  through  a  per- 
foration. In  each  instrument  the  blades  were  perforated.  These 
varieties  represent  the  modifications  devised  by  the  Chamberlen 
family,  though  there  is  uncertainty  as  to  which  is  the  oldest. 

These  forceps  and  all  others  introduced  up  to  the  middle  of 
the  eighteenth  century  were  probably  used  only  in  cases  in  which 
the  head  was  delayed  below  the  pelvic  brim.  They  were  straight, 
with  the  exception   of  the  curve  of  the  blades,  meant  to  fit  the 


68o 


THE   FORCEPS. 


fetal  head,  and  known  as  the  cranial  or  cephalic  curve.  After- 
ward this  instrument  became  known  as  the  short  forceps,  to  dis- 
tinguish it  from  the  later  instrument  possessing  a  pelvic  curve — 
termed  long  or  curved. 

There  has  been  some  dispute  as  to  who  introduced  the  first 
great  improvement  in  the  forceps — viz.,  the  pelvic  curve.  It  was 
undoubtedly  first  made  public  by  Levret,  who  demonstrated  the 
improved  instrument  in  the  Royal  Academy  of  Surgery  of  Paris, 
in  1747,  his  account  being  published  in  175 1.  In  1740  Benjamin 
Pugh,  of  Chelmsford,  England,  had  independently  devised  the 
pelvic  curve,  though  he  did  not  describe  it  until  1754.  Smellie 
also,  in  his  text-book  published  in  1752,  states  that  he  had  made 
the  same  improvement  several  years  previously,  and  that  he  had 
used  the  forceps  in  his  private  practice.     Pugh's  claim  has  never 


Fig.  286.— Three  varieties  of  the  original  Chamberlen  forceps. 

been  widely  recognized,  the  curve  having  been  generally  named 
"after  Levret  or  Smellie.  The  introduction  of  this  curve,  whereby 
the  forceps  could  be  made  to  grasp  the  head  high  at  the  brim,  in 
virtue  of  being  able  to  follow  the  axis  of  the  pelvis,  must  be  re- 
garded as  the  first  advance  in  the  evolution  of  the  instrument. 

The  next  improvement  was  the  addition  of  an  inverted  or 
"  perineal  "  curve.  This  was  first  described  by  Wallace  Johnson, 
of  London,  in  1769.  This  curve  was  added  in  order  that,  in  his 
own  words,  "  the  perineum  maybe  saved  from  injury, the  extract- 
ing force  rigidly  conducted,  and  the  handles  at  the  same  time 
kept  from  pressing  uneasily  on  the  inferior  and  anterior  parts  of 
the  pubes."     This  improvement  was   not  generally  appreciated. 


HISTORIC. 


68 1 


the  long  or  curved  forceps  of  Smellie  and  Levret  and  the  older 
short  or  straight  forceps  being  used  almost  exclusively  until  after 
the  middle  of  the  nineteenth  century. 

Hubert,  of  Louvain,  while  recognizing  that  the  perineal  curve 
of  Johnson  added  slightly  to  the  advantage  of  forceps  having  a 
pelvic  curve,  evolved  from  it  the  improvement  known  as  the 
"  compensation  curve,"  which  must  be  regarded  as  the  second 
important  advance  in  the  evolution  of  the  forceps.  In  i860  he 
proposed  to  bend  back  the  free  ends  of  the  handles  at  a  right 
angle,  and  in  1866  to  attach  to  the  handles,  near  the  lock,  a  bar, 
through  which  traction  could  be  made  directly  in  the  line  of  the 
chord  of  the  pelvic  curve  of  the  instrument.  His  object  was  to 
pull  the  head  in  the  proper  axis  of  the  pelvic  inlet  with  less  dif- 
ficulty and  uncertainty  than  accompanied  the  use  of  the  simple 


Fig.  287. — Early  pattern  of  Tarnier's  axis-traction  forceps.     Tlie  dotted  line  indicates 
the  position  of  the  traction  rods  when  they  lie  close  to  the  shank  of  the  instrument. 

curved  forceps.  Hubert's  instrument  was  little  appreciated  or 
used  by  the  profession.  In  1868  Aveling,  of  London,  advocated 
the  use  of  a  perineal  curve.  Morales,  of  Belgium,  in  1871,  intro- 
duced an  instrument  embodying  this  principle. 

In  1877  Tarnier,  of  Paris,  published  a  memoir  in  which  he 
demonstrated  the  value  of  the  compensation  curve,  but  showed 
that  the  principle  could  be  more  advantageously,  safely,  and  con- 
tinuously employed  by  attaching  curved  rods  to  the  blades  of  the 
ordinary  forceps  by  movable  joints,  traction  being  carried  out  by 
means  of  a  bar  attached  to  the  outer  ends  of  the  rods,  hence 
termed  the  traction  handle.  Tarnier's  improvement  has  been  the 
last  .stage  in  the  evolution  of  the  forceps.  Through  it  the  delivery 
of  the  head  is  possible  with  the  least  loss  and  misdirection  of  the 


682  .  THE   FORCEPS. 

force  expended,  and  with  the  most  perfect  approximation  to  the 
axis  of  the  pelvis.  The  instrument  thus  modified  is  known  as  the 
axis-traction  forceps.  Tarnier  first  added  the  rods  to  an  instru- 
ment possessing  a  perineal  as  well  as  a  pelvic  curve.  A.  R. 
Simpson  showed  that  the  former  was  unnecessaiy,  the  rods  giving 
the  same  advantages  when  applied  to  forceps  with  only  the  pelvic 
curve.  Tarnier  later  adopted  this  arrangement.  This  authority 
did  not  at  first  recognize  the  superiority  of  the  instrument  in  de- 
livering the  head  through  the  outlet,  for  he  taught  that  as  soon 
as  the  head  begins  to  extend  at  the  outlet,  the  rods  and  applica- 
tion handles  should  be  grasped  together,  the  instrument  being 
used  as  a  long  forceps.  A.  R.  Simpson  and  Milne  Murray  have 
particularly  insisted  upon  the  harmfulness  of  this  practice,  and 
state  that  with  a  proper  instrument  the  head  can  be  extracted  in 
the  right  direction  with  the  least  danger  to  the  maternal  tissues. 
The  author  desires  to  emphasize  this  statement,  and  to  support 
those  who  have  found  that  the  head  can  be  delivered  with  much 
less  risk  to  the  perineum  than  is  possible  with  any  other  forceps. 
Since  the  introduction  of  the  axis-traction  instrument  its  superior 
advantages  have  slowly  but  surely  gained  recognition,  in  spite  of 


Fig.  288. — Forceps  of  Dubois. 

much  opposition  on  the  part  of  those  accustomed  to  the  long 
forceps. 

It  has  been  claimed  by  Albert  Smith  and  others  that  Tarnier's 
forceps  was  merely  the  readaptation  of  a  device  introduced  by 
Hermann,  of  Berne,  in  an  instrument  introduced  by  this  worker 
in  1844.  Hermann  realized  the  imperfections  of  the  long  forceps, 
especially  the  difficulty  of  pulling  the  head  without  loss  and  mis- 
direction of  force,  and  he  added  a  couple  of  straight  rods  with 
handles.  These  fitted  into  depressions  close  to  the  lock  of  the 
forceps,  and  could  be  attached  so  as  to  lie  on  the  pubic  or  sacral 
side.  In  the  former  position  they  were  used  to  push  the  shanks 
of  the  forceps  backward  ;  in  the  latter,  to  pull  them  back.  It  is 
now  generally  admitted  that  Hermann's  instrument  in  no  respect 
embodied  the  principle  of  axis  traction.  While  it  was  meant  to 
reach  the  same  end,  its  action  was  the  same  as  that  of  any  long 
forceps  used  with  Pajot's  maneuver.  Hermann's  instrument  did 
not  become  popular,  because  it  offered  no  real  advantages  over 
the  ordinary  long  forceps  manipulated  with  the  hands. 

It  is  interesting  to  note  that  Chassigny,  in  i860,  introduced  an 
instrument  in  which  traction  was   made   not   by  the  application 


HISTORIC. 


683 


handles,  but  by  a  cord  that  was  attached  to  a  bar  placed  across 
the  fenestrum.  Chassigny  pointed  out  what  has  since  been  well 
recognized  in  the  construction  of  the  axis-traction  forceps,  that 
when  the  blades  are  applied  to  the  head,  they  may  be  displaced 
during  traction  around  a  hypothetic  axis  joining  the  centers  of 
the  blades.  He  held  that  this  could  not  occur  if  traction  were 
made  from  this  imaginary  axis,  and  introduced  the  transverse  bars 


Fig.   289. — One  variety  of    Hermann's    forceps    represented    as    applied    to    head  in 
pelvis:  a.  Application  handles;  b,  traction  handle  (Milne  Murray). 

for  the  purpose  of  attaching  cords  on  which  traction  was  made 
during  delivery. 

Since  Tarnier's  instrument  was  introduced  many  varieties  have 
been  made.  A.  R.  Simpson  was  one  of  the  first  to  adopt  the 
axis-traction  forceps  outside  of  France,  and  to  his  advocacy  is 
mainly  due  the  widespread  use  of  the  instrument  in  Scotland. 
He  added  traction  rods  to  the  well-known  long  forceps  of  Sir 
J.  Y.  Simpson,  modifying    the    handles  somewhat,    the  traction 


Fig.  290. — So-called  axis-traction  forceps  of  Breus  (the  rods  having  right-angled  bend 
are  against  shank  when  application  is  made). 

handle  being  permanently  attached  to  one  of  the  traction  rods. 
Lusk,  in  America,  applied  the  principle  to  the  Wallace  pattern 
of  forceps.  Sanger  adopted  the  principle  in  Germany,  and  first 
used  a  cumbrous  arrangement  of  leather  straps  for  the  purpose. 
This  he  abandoned  in  favor  of  traction  rods,  which  he  at- 
tached to  the  ])usch  pattern  of  long  forceps.     Breus's  instrument 


684 


THE  FORCEPS. 


is  very  inferior  to  the  Tarnier  type  ;  it  consists  of  a  pair  of  blades 
to  which  fixed  rods  are  attached  anteriorly,  the  application  shanks 
and  handles  being  attached  by  a  movable  joint.  Though  the 
small  rods  may  indicate  the  direction  of  the  movement  of  the 
head,  the  construction  of  the  instrument  may  be  easily  demon- 
strated, both  mathematically  and  in  practice,  to  be  very  faulty  as 
a  means  of  affording  axis  traction. 

In  the  construction  of  the  various  patterns  of  axis-traction  for- 


FlG.  291. —  Forceps  of  Simpson. 

ceps  sufficient  regard  has  not  been  paid  to  precision  in  detail. 
Murray  has  done  good  service  in  insisting  that  a  common  standard 
of  accuracy  should  be  devised,  and  that  mechanical  devices  should 
be  adjusted  to  mathematic  principles.  Various  minor  peculiari- 
ties are  retained  in  forceps  made  in  different  countries.  English 
and  American  instruments  generally  possess  the  lock  devised  by 
Smellie,  consisting  of  a  shoulder  projecting  from  each  half  The 
French  lock  is  composed  of  a  pivot  on  one  half,  which  fits  into  a 
hole  on  the  other  half,  a  screw  top  holding  them  together.     The 


Fig.  292.— French  {A)  and  English  {D)  locks. 

German  lock  has  a  fixed  pivot,  with  a  button  top  on  one  half, 
which  fits  into  a  lateral  notch  on  the  other.  The  cross-knees  on 
the  handles  of  many  forceps  were  a  German  invention.  In  French 
forceps  the  ends  of  the  handles  are  bent  outward.  In  the  axis- 
traction  forceps  the  application  handles  need  neither  the  knees  nor 
the  curved  ends  ;  as  they  are  not  used  in  traction,  they  should  be 
as  light  as  possible. 

Mechanical  Principles  of  the  Forceps. — A  good  idea 


MECHANICAL    PRINCIPLES    OF   THE   FORCEPS. 


685 


of  the  relative  values  of  the  different  types  of  forceps  that  I  have 
described  may  be  trained  by  the  following  comparative  study  : 

Straight  or  Short  Forceps. — The  inadequacy  of  this  instru- 
ment in  a  case  in  which  the  head  is  at  the  brim  in  an  occipito- 
anterior position  is  easily  demonstrated.  In  introducing  the  blades 
it   is    difficult   to   apply  them   to   the   head   symmetrically — /.  e., 


Fig.  293. — Forceps  with  Reynold's  traction  hooks  applied.     Such  an  instrument  very 
imperfectly  and  inadequately  represents  the  axis-traction  principle. 

neither  too  far  back  nor  too  far  forward,  because  the  straight  in- 
strument cannot  follow  the  pelvic  curve  ;  indeed,  it  is  usually 
impossible  without  marked  pushing  backward  of  the  perineum 
and  coccyx.      An  asymmetric   grasp  of  the  head  too  near  the 


Fk;.  294. — Application  of  straight  forceps  at  brim  (Milne  Murray)  :  c-i.  Conjugate 
of  brim  ;  a-b,  axis  of  brim  ;  c-d,  axis  of  outlet ;  e-f,  axis  of  forceps  and  line  of  traction  ; 
b-x-f,  angle  of  error. 

sinciput  tends  to  undo  the  normal  flexion  that  exists,  and  so  to 
increase  the  difficulty  in  delivery.  But  supposing  that  the  head 
could  be  grasped  properly,  the  disadvantages  connected  with 
traction  are  great.      In  the  first  place  the  blades  are  held  against 


686 


THE  FORCEPS. 


the  head  by  the  compression  of  the  handles  as  traction  is  made. 
This  is  always  a  source  of  danger  to  the  fetus,  owing  to  the  risk 
of  causing  too  great  pressure.  The  greatest  disadvantage,  how- 
ever, is  that  there  is  a  great  loss  of  the  power  exercised,  and  the 
loss  is  represented  by  undue  compression  of  the  maternal  soft 
parts  against  the  bony  canal.  This  is  illustrated  in  the  diagram. 
E-f  indicates  the  line  along  which  traction  is  made ;  a-b  is 
the  axis  of  the  pelvic  brim,  in  the  direction  of  which  the  head 
enters  the  bony  canal.  As  these  lines  are  not  parallel,  it  is  evi- 
dent that  the  actual  force  is  resol\-ed  into  two  portions,  one  of 
which,  the  effecti\e,  draws  the  head  in  the  axis  of  the  brim ;  the 
other,  the  ineffective,  being  wasted  irr  pressing  the  head  against 
the  soft  tissues  resting  on  the  pubes. 

It  is,  therefore,  evident  that  when  the  head  is  occipito-anterior 
and  at  the  brim,  the  straight  forceps  may  not  onl}^  be  of  little 
-assistance,  but  may  actually  increase  the  difficulty  by  pulling 
down  the  sinciput.  When  the  head  lies  in  the  bony  pelvis,  the 
disadvantages  of  the  instrument  are  reduced,  but  they  still  exist. 


Fig.  295. — Application  of  curved  forceps  at  brim  (Milne  Murray):  c-l.  Conjugate 
of  brim  ;  a-b,  axis  of  inlet  ;  c-f,  axis  of  forceps  and  line  of  traction  ;  b-x-f,  angle  of 
error. 


Here  also  the  head  should  be  directed  in  the  axis  of  the  lower 
part  of  the  canal,  with  the  least  expenditure  of  energy  and  damage 
to  maternal  tissues.  With  these  forceps  the  proper  line  of  traction 
is  usually  guesswork,  and  usually  brute  force  is  made  to  over- 
ride all  considerations  of  strategy. 

Some  authorities  hold  that  the  straight  forceps  has  at  least  a 
place  in  cases  in  which  the  occipital  end  of  the  head  is  posterior. 
They  hold  that  the  blades,  grasping  the  head  toward  the  back, 
favor  increased  flexion  when  traction  is  made,  and  also  that  the 
absence  of  a  pelvic  curve  allows  rotation  of  the  forceps  to  take 


MECHANICAL    PRINCIPLES   OF   THE   FORCEPS.  68/ 

place  if  the  occiput  turns  to  the  front,  with  Httle  risk  that  the  ends 
of  the  blades  may  cut  the  maternal  soft  parts.  The  first  of  these 
advantages  may  readily  be  granted  ;  the  second  must  be  modified. 
Without  doubt  rotation  of  the  head  with  straight  forceps  is  less 
dangerous  than  with  the  curved  instrument,  but  rotation  itself 
must  be  more  or  less  interfered  with  by  the  exercise  of  traction 
through  the  handles,  whose  compression  keeps  the  blades  applied 
to  the  head.  This  very  compression  is  apt  to  be  excessive  with 
such  an  instrument,  and  consequently  dangerous  to  the  fetus. 

Long  or  Curved  Forceps. — When  this  instrument  is  used  to 
deliver  a  head  situated  at  the  brim,  what  are  its  advantages  over 
the  straight  forceps  ?  The  chief  one  is  that,  owing  to  the  pelvic 
curve  on  the  instrument,  it  is  more  easily  passed  along  the  genital 
canal,  so  that  the  blades  may  rest  properly  against  the  head. 
The  latter  is  grasped  symmetrically,  so  that  when  traction  is  ex- 


FiG.  296. — Hubert's  forceps  applied  at  brim  (Milne  Murray) :  a-b,  Axis  of  inlet  corre- 
sponds with  direction  of  traction,  hence  angle  of  error  has  disappeared. 

ercised,  the  sinciput  is  not  displaced  downward  so  as  to  induce 
extension  and  so  to  increase  the  difficulty  of  delivery.  Apart  from 
this  the  instrument  has  the  disadvantages  of  the  straight  forceps. 
The  operator,  in  pulling,  compresses  the  handles  and  is  apt  to  injure 
the  fetal  skull  or  brain  or  to  stimulate  the  respiratory  center.  But 
the  great  disadvantage  is  that  part  of  the  actual  force  is  ineffective 
and  misused  in  pressing  the  head  against  the  maternal  tissues. 
As  the  head  descends  there  is  no  means  of  knowing  accurately 
how  to  pull  to  the  best  advantage,  with  the  least  resistance  and 
danger  to  the  tissues.  Different  rules  have  been  given  in  regard 
to  the  manipulations  to  be  employed.  One  of  the  best  known 
methods  is  Pajot's  maneuver,  in  which  one  hand  is  used  to  pull 
directly  downward,  while  the  other,  placed  near  the  shanks, 
presses  them  downward  and  backward,  acting  as  a  kind  of  movable 


688 


THE   FORCEPS. 


fulcrum,  the  combined  manipulations  being  for  the  purpose  of 
making  the  head  follow  the  normal  curv^e  of  the  pelvis,  with  the 
least  waste  of  power  and  the  least  pressure  against  maternal 
tissues.  It  is  very  evident  that  success  depends  upon  the  co- 
ordination of  the  amount  and  direction  of  the  force  exerted  by 
each  hand.  This  is  a  matter  of  skilled  judgment,  which  is  the 
product  of  individual  endowment  and  experience.  In  a  case  de- 
manding traction  on  the  head  through  the  entire  length  of  the 
curved  canal,  the  adjustment  of  the  combined  forces  varies  at 
successive  stages  of  the  passage.  Consequently  the  successful 
employment  of  the  forceps  must  be  considered  a  complex  and 
difficult  procedure. 

Compensation=curve  Forceps. — Hubert's  instrument  applied 
to  the  head  at  the  brim  of  a  normal  pelvis  has  one  advantage  over 
the  long  forceps  when  traction  is  first  made.  The  rod  attached 
to  the  handle  is  of  such  a  length  so  that  when  it  is  pulled  the  line 


Fig.  297. — "  Pajot's  maneuver"  (Milne  Murray). 

of  traction  corresponds  with  the  axis  of  the  inlet,  no  force  being 
wasted.  But  when  the  head  has  entered  that  part  of  the  pelvic 
cavity  whose  axis  curves,  there  is  no  means  of  knowing  in  what 
direction  the  handles  should  be  pulled,  and  the  instrument  hence- 
forth acts  only  as  the  long  forceps,  adjustment  being  constantly 
necessar}'. 

Axis=traction  Forceps. — When  this  instrument  is  applied  to  a 
head  at  the  brim  of  the  normal  pelvis,  the  great  advantage  in 
traction  is  that  the  force  may  be  exercised  during  the  entire  proc- 
ess, so  that  the  head  is  made  to  move  in  the  proper  axis  along 
the  entire  length  of  the  canal.  The  blades  are  practically  one 
with  the  head  of  the  child,  and  the  application  handles  indicate 
the  direction  in  which  the  head  is  moving.  As  long  as  the  operator 
keeps  the  upper  parts  of  the  traction  rods  parallel  with  the  shanks 


MECHANICAL    PRINCIPLES   OF   THE   FORCEPS. 


689 


of  the  forceps  during  traction  he  may  feel  assured  that  he  is  using 
his  power  to  the  best  advantage. 

At  the  outlet  the  instrument  may  also  be  most  advantageously 
used  and  is  able  to  deliver  the  head  in  the  proper  direction  better 
than  the  long  forceps,  and  with  diminished  risk  to  the  perineum. 
If  the  limbs  be  allowed  to  hang  down,  as  in  the  Walcher  position, 
during  the  passage  of  the  outlet,  the  danger  of  injuring  the  soft 
parts  to  any  marked  extent  is  greatly  reduced. 

Both  for  scientific  and  practical  reasons  the  axis-traction  forceps 
should  entirely  displace  the  older  instruments.  The  chief  ob- 
stacle to  the  wider  use  of  the  former  has  been  the  prejudice  of 
those  whose  argument  is  that  they  have  often  enough  been  suc- 
cessful with  the  older  instrument.  This  statement  is  on  a  par 
with  that  made  by  the  man  who  says  that  he  enjoys  a  ride  on  an 
old-fashioned  velocipede,  and  sees  no  reason,  therefore,  why  he 


Fig.  298. — Diagram  of  Tarnier's  forceps  at  brim.  The  traction  bar  of  Hubert's 
instrument  is  continued  up  by  a  rod  that  is  fi.xed  by  a  movable  joint  at  lower  end  of 
blade  (Milne  Murray). 

should  change  to  the  latest  improved  bicycle ;  nor  will  he  under- 
stand until  he  has  made  a  thorough  comparison  of  the  machines. 
A.  R.  Simpson  has  well  said :  "  If  a  practitioner  accustomed  only 
to  the  use  of  the  old  forceps  will  use  the  axis-traction  forceps 
in  one  or  two  difficult  cases  he  will  find  that  it  works  with  so 
much  safety  to  the  mother  and  child,  and  with  so  much  ease  to 
himself,  that  he  will  ever  after  use  it  in  every  case.  There  is 
no  case,  high  or  low,  with  presentation  and  position  normal  or 
abnormal,  demanding  forceps  delivery  where  the  axis-traction 
instrument  may  not  be  applied.  Since  it  came  into  use  the  range 
of  forceps  application  has  been  greatly  widened,  and  the  sphere 
of  the  competing  operations,  such  as  turning,  embryotomy,  and 
induction  of  premature  labor,  has  been  correspondingly  nar- 
rowed." 
44 


690 


THE   FORCEPS. 


Construction  of  Axis-traction  Forceps. — The  instru- 
ment introduced  by  Tarnier,  and  the  adaptations  of  other  work- 
ers, have  all  been  constructed  with  reference  to  pelves  possessing 
the  normal  curve.  Some  authorities,  who  have  admitted  the  cor- 
rectness of  the  principle  of  axis  traction,  have  denied  its  attain- 
ability in  practice,  owing  to  the  variations  found  in  the  curves  of 
pelves  and  to  the  impossibility  of  accurately  determining  the 
curve  in  any  given  woman.  This  objection  has  some  weight 
when  applied  to  deformed  pelves  that  deviate  markedly  from  the 
normal ;  it  is  of  no  value  as  applied  to  the  great  majority  of 
pelves  in  which  the  variation  is  slight.  Moreover,  as  Milne 
Murray  states,  if  we  are  working  in  a  canal  of  doubtful  curvature 
with  an  instrument  whose  construction  is  unknown,  we  are  ex- 
posed to  two  sources  of  error;  if,  on  the  other  hand,  we  are  in 
doubt  as  to  the  canal  and  have  definite  knowledge  of  the  instru- 
ment, the  element  of  error  is  diminished  by  one-half  He  has 
insisted  that  the  forceps   should  be   made  in  conformity  with  a 


Fig.  299. — Milne  Murray's  ordinary  axis-traction  forceps. 

standard  scale  by  instrument  makers,  in  order  that  purchasers 
should  be  able  to  judge  for  themselves  as  to  the  correctness  of 
any  given  instrument.  As  his  instrument  has  been  constructed 
with  great  mathematic  accuracy,  I  shall  describe  it.  He  has 
made  two  patterns,  one  referable  to  pelves  with  the  normal 
curve,  another  capable  of  being  adapted  to  pelves  of  different 
curves. 

I.  The  Forceps  Constructed  in  Reference  to  the  Normally 
Curved  Pelvis. — The  instrument  is  made  entirely  of  steel,  of 
light  but  rigid  construction.  There  is  a  well-marked  pelvic  curve, 
whose  arc  has  a  radius  of  7  in.,  the  length  of  the  chord  of  the 
blades  measuring  5|  in.  The  shanks  are  2\  in.  in  length,  the 
handles  6  in.,  and  they  are  in  one  straight  line.  The  chord  of  the 
pelvic  curve  forms  an  angle  of  1 20°  with  the  shanks.  The  halves 
of  the  forceps  fit  together  by  a  Smellie  lock  placed  at  the  junction 


CONSTRUCTION   OF  AXIS-TRACTION  FORCEPS. 


691 


of  the  shanks  and  handles,  and  a  fixation  screw  is  attached,  so 
that  they  may  be  kept  in  position  when  used.  The  blades  have 
a  cephalic  curve  of  such  a  size  so  that,  when  fitted  together,  the 
distance  between  the  ends  of  the  blades  is  not  less  than  i  in.,  and 
that  between  the  middle  of  the  blades  not  less  than  3  in.  The 
fenestrum  in  each  blade  is  4  in.  in  length ;  between  it  and  the 
shank  is  a  length  of  solid  blade  if-  in.  in  length.  The  traction  rods 
are  hinged  to  the  blades,  behind  the  fenestra,  by  a  screw  nut,  and 
are  capable  of  anteroposterior  movement  only.  The  upper  part 
of  each  rod  bends  back  and  runs  parallel  to  the  shanks  and  han- 
dles, being  close  behind  them,  so  as  to 
save  room  and  avoid  undue  pressure 
against  the  perineum.  The  rods  curve 
downward  i  in.  behind  the  lock  and 
end  in  two  flattened  surfaces,  in  which 
fit  the  studs  of  the  traction  handles.  It 
is  important  that  the  rods  should  not 
bend  back  too  high,  because  in  high 
forceps  application  it  is  important  that 
a  portion  of  the  rods  running  parallel 
to  the  shanks  should  be  visible  outside 
of  the  vulva.  The  traction  handle  is 
attached  to  the  ends  of  the  rods,  so 
that  when  the  upper  parts  of  the  rods 
lie  close  to  the  shanks,  a  line  uniting 
the  traction  bar  and  the  attached  end 
of  each  rod  is  tangential  to  the  middle 
of  the  arc  of  the  pelvic  curve.  The 
rods  are  held  together  by  a  simple 
device  attached  a  short  distance  above 
the  lower  ends.  They  should  be 
bound  before  traction  is  applied,  in 
order  that  the  force  may  be  equally 
distributed  along  both  rods.  Murray 
has  more  recently  modified  the  instru- 
ment by  attaching  the  traction  rods  to 
the  blades  without  the  use  of  any 
screw  or  nut,  and  by  placing  the  fixa- 
tion screw,  which  holds  the  handles 
together,  at  the  ends  of  the  applica- 
tion handles. 

This  author  has  published  a  pro- 
jection of  his  forceps,  with  which  any 
specimen  of  his  instrument  may  be  compared.  He  has  also 
shown  how  it  is  possible  to  test  the  accuracy  of  any  pair  of 
axis-traction  forceps.  One  half  should  be  traced  in  profile  on 
a  piece   of  paper,  as  in  Fig.  300.      x  is  the  tip  of  the  blade,  y 


Fig.  300. — Mechanical  construc- 
tion of  axis-traction  forceps :  x, 
Center  point  of  blade  tip  ;  j/,  junc- 
tion of  blade  and  shank ;  x-y, 
chord  of  arc  of  blade  ;  x,  v,  y,  arc 
of  blade  ;  ^-^ bisects  chord  at  right 
angles;  q,  x,  v,  y,  li,  circle  whose 
center  is  on  e-f,  and  of  which  x,  v, 
y,  is  an  arc  ;  a-b,  tangent  to  arc  at 
V ;  V,  theoretic  position  for  at- 
tachment of  traction  rods  ;  2,  best 
practicable  position  for  their  at- 
tachment ;  z-t,  traction  rod  (Milne 
Murray). 


692  ^  THE   FORCEPS. 

the  junction  of  the  blade  and  shank.  Join  these  points  by  a 
straight  Hne,  x-y.  Bisect  this  by  a  perpendicular,  c-f.  Draw  a 
circle  passing  through/,  v,  x,  whose  center  is  in  c-f ;  the  diameter 
of  this  circle  should  be  about  7  in.  Then  draw  a  tangent,  a-b,  to 
this  circle  at  v,  where  c—f  crosses  the  circumference,  a-b  is 
parallel  to  the  chord  x-y.  The  forceps  should  then  be  replaced 
on  the  paper,  the  traction  rods  close  to  the  shanks.  If  the  instru- 
ment is  properly  made,  the  free  ends  of  the  rods  should  lie  on  the 
tangent  a-b,  and  the  traction  handles  should  be  so  attached  as  to 
pull  in  this  line.  The  diagram  shows  that  7'  is  the  theoretic  point 
to  which  the  traction  rods  should  be  attached,  because  when 
traction  is  exerted,  there  is  no  tendency  to  the  displacement  of  the 
blades,  and  the  application  handles  are  not  interfered  with  in  their 
function  as  an  indicator  of  the  direction  in  which  the  head  moves 
and  in  which  traction  is  to  be  made.  Now  v  is  seen  to  lie  in  the 
fenestrum ;  consequently,  if  the  rods  are  to   be  attached  at  this 


Fig.  301. — Milne  Murray's  new  axis-traction  forceps,  capable  of  adjustment  to 
pelves  of  different  curves.  The  outer  ends  of  the  traction  rods  are  bent  at  right  angles, 
and  on  them  the  traction  handle  may  be  fastened  at  any  point. 

point,  the  fenestrum  must  be  much  reduced  in  size  or  a  bar  must 
be  placed  across  it  at  i',  as  in  Poullet's  instrument.  This  is  inad- 
visable, for  if  the  bar  be  small,  it  may  break  and  may  injure  the 
head,  as  well  as  prevent  the  latter  from  bulging  into  the  fenestrum. 
It  is  advisable  to  have  a  large  fenestrum,  in  order  that  the  head 
may  bulge  into  it.  The  rods  are,  therefore,  attached  behind  the 
fenestrum ;  the  resulting  error  is,  however,  of  little  practical  im- 
portance and  may  be  disregarded. 

2.  The  Forceps  Constructed  in  Reference  to  Pelves  of  Dif= 
ferent  Curves. — It  is  evident  that  a  forceps  constructed  with 
reference  to  a  normal  pelvis  must  be  used  with  a  certain  amount 
of  error  in  an  abnormal  pelvis,  especially  when  the  head  is  high 
at  the  brim,  for  in  these  cases  the  line  of  traction  and  the  pelvic 
axis  do  not  coincide.  In  a  flat  pelvis  the  axis  of  the  inlet  is 
inclined  somewhat  farther  back,  and  in  a  justominor  or  masculine 


CONSTRUCTION   OF  AXIS-TRACTION  FORCEPS. 


693 


pelvis  a  little  farther  forward,  than  in  a  normal  pelvis.  This  is 
well  illustrated  in  Murray's  diagrams  (Fig.  302).  Hence  in  these 
abnormal  conditions,  with   the  axis-traction  forceps  already  de- 


FlG.  302. — Comparison  of  inclination  of  axes  in  (l)  normal,  (II)  flat,  and  (ill)  justo- 
minor  pelves  :  a-b.  Verticals  through  coccyx ;  c-d,  verticals  through  symphysis ;  a-c, 
horizontal  through  promontory  ;  b-d,  horizontal  through  coccyx.  The  diagonals,  c-b, 
indicate  the  relative  inclination  of  line  of  traction  through  brim  (Milne  Murray). 

scribed,  some  of  the  force  is  inefficient,  since  the  line  of  traction 
crosses  the  axis  of  the  brim  at  an  angle.  To  meet  this  difficulty 
Murray  has  constructed  an  instrument  suitable  for  all  such  con- 
ditions.    It  is  similar  to  the  forceps  already  described,  save  in  the 


Fig.  303. — Illustrating  application  of  A.  R.  Simpson's  axis-traction  forceps  when 
head  is  low  in  pelvis.  Left  blade  is  in  position,  and  right  one  is  represented  as  being 
introduced  into  vulva  (A.  R.  Simpson). 

arrangement  of  the  traction  rods.  These,  after  running  down 
close  to  the  shanks  and  handles,  turn  downward  at  a  point  2\  in. 
?jehind  the   lock,  and   run  at  right  angles  for  a  distance  of  4  in. 


694  .  THE   FORCEPS. 

These  horizontal  limbs  lie  close  together  and  are  marked  off  into 
lengths  of  \  in.,  being  numbered  from  o  to  7.  The  traction 
handle  fits  on  these  limbs  by  a  pierced  block,  which  can  be  fixed 
at  any  point  by  a  screw.  At  one  point  is  placed  the  word 
"  normal."  When  the  handle  block  is  fixed  at  this  level,  the 
instrument  is  ready  for  use  in  a  normal  pelvis.  To  adapt  the 
position  of  the  handle  of  the  instrument  to  a  pelvis  in  which  the 
axis  of  the  inlet  is  anterior  to  the  normal  axis,  the  block  is 
moved  nearer  the  application  handles.  To  adapt  it  for  a  flat 
pelvis,  in  which  the  brim  axis  is  pushed  back,  the  block  is  moved 
toward  the  free  ends  of  the  horizontal  limb.  In  using  the  instru- 
ment when  it  is  adjusted,  the  guide  to  the  direction  of  the  traction 
is  the  relation  of  the  traction  rods  and  shanks ;  they  should 
always  be  parallel. 

Of  course,  it  must  be  admitted  that  variations  in  the  inclination 
of  the  pelvis  are  difficult  to  determine  accurately,  and  that  the 
adjustment  of  the  instrument  will  rarely  be  exactly  what  it  should 
be,  but  the  partial  removal  of  an  error  is  better  than  no  removal 
at  all.  Moreover,  it  is  easy  to  alter  the  position  of  the  traction 
handles  until  a  point  is  found  at  which  the  best  results  are  ob- 
tained. There  is  no  doubt  that  this  instrument  combines  scientific 
accuracy  with  practical  adaptability  as  does  no  other  forceps  yet 
constructed. 

Indications  for  the  Use  of  Forceps. — The  forceps  is  to 
be  used  only  after  complete  dilatation  of  the  cervix,  either  in 
labors  unduly  prolonged  or  in  conditions  where  dangers  to  mother 
or  child  exist. 

1.  In  Delayed  Labors. — i.  Faults  in  the  powers — /.  r.,  uterine 
inertia,  manifested  by  weak  or  irregular  pains  ;  absence  or  weak- 
ness of  the  accessory  muscles  ;  wasted  uterine  force,  as  when  the 
fundus  is  deviated  forward,  so  that  the  long  axis  of  the  uterus 
does  not  correspond  to  that  of  the  brim. 

2.  Faults  iu  the  Passages. — {a)  Soft. — When  there  is  abnormal 
resistance  on  the  part  of  the  vagina  and  vulva,  from  conditions 
inherent  to  the  walls  or  due  to  causes  external  to  them,  forceps 
may  be  necessary.  Frequently,  especially  in  primiparae,  the  chief 
difficulty  is  found  in  the  perineum. 

{I))  Hard. — In  contracted  conditions  of  the  hard  passage,  in  its 
whole  extent  or  in  any  part,  the  forceps  is  often  used.  In  the  past 
the  pelves  in  which  it  was  most  frequently  employed  were  the 
justominor,  the  male,  and  the  funnel-shaped.  In  recent  years, 
owing  to  the  work  of  Milne  Murray,  the  axis-traction  instrument 
has  also  proved  serviceable  in  certain  flat  pelves.  (These  various 
pelves  are  referred  to  in  the  chapter  on  Pelvic  Deformities.) 

3.  Faults  in  the  Passefiger. — A  head  slightly  larger  than  nor- 
mal, or  one  abnormally  ossified,  which  will  not  mould  well,  may 
sometimes  need  to  be  extracted  by  forceps.     In  occipitoposterior 


FUNCTION  OF  THE  FORCEPS.  695 

and  in  certain  face  cases  it  may  be  indicated.  In  extension  of 
the  head  after  dehvery  of  the  body  in  breech  cases  it  may  also  be 
used  to  extract  the  head.  Occasionally  in  delayed  breech  cases  it 
may  be  applied  to  the  breech. 

II.  Dangerous  Labors. — In  various  maternal  complications — 
e.g.,  eclampsia,  hemorrhage,  heart  disease,  pneumonia,  etc. — and  in 
certain  complications  on  the  part  of  the  fetus — e.g.,  asphyxiation 
from  any  cause,  prolapsus  funis,  etc.,  forceps  may  be  needed. 

Function  of  the  Forceps. — The  chief  essential  use  of  the 
forceps  is  as  a  tractor,  the  instrument  replacing  or  supplementing 
the  natural  expulsive  powers.  In  the  older  books  various  other 
functions  are  mentioned — c.  g.,  compression,  rotation,  leverage, 
and  dynamic  action. 

Whenever  the  forceps  is  applied  to  the  head,  compression  un- 


FlG.  304. — A.  R.  Simpson's  axis-traction  forceps  applied  to  head  lying  low  in  pelvis. 
The  illustration  represents  locking  together  of  traction  rods. 

doubtedly  is  produced.  With  the  axis-traction  forceps  this  is 
slight ;  with  the  short  or  long  forceps  it  is  greater,  because  the 
hands,  in  exerting  traction,  are  used  to  keep  the  handles  together 
and  can  scarcely  fail  to  compress  the  head  unduly.  The  most 
marked  compression  occurs  when  the  head  is  grasped  antero- 
posteriorly  or  obliquely.  Injury  may  be  done  to  the  skull  or 
intracranial  structures,  yet  frequently  marked  anteroposterior 
telescoping  of  the  bones  may  be  produced  without  injury.  It  has 
generally  been  held  that  anteroposterior  compression  causes  trans- 
verse compensatory  bulging.  Murray  has  shown  that  bulging 
takes  place  in  a  vertical  direction,  and  that,  therefore,  a  long-held 
objection  to  the  use  of  forceps  in  flat  pelves  is  removed.  It  is 
important  to  note  that  the  more  the  head  is  compressed,  the  more 


696  THE  FORCEPS. 

moulding  and  adaptation  to  the  birth  canal  is  prevented.  The 
purposeful  application  of  compression  by  the  forceps  is  inadvisable. 
Ordinarily  the  blades  should  mark  the  head  slightly  or  not  at  all. 
Rotation  of  the  head,  when  the  forceps  is  used,  may  frequently 
occur  in  association  with  adaptation  movements.  Intentional  rota- 
tion produced  forcibly  with  the  instrument  is  dangerous  both  to 
maternal  and  fetal  tissues,  and  should  rarely  ever  be  carried  out, 
even  by  expert  operators.  As  rotation  occurs,  when  the  forceps 
is  in  use,  it  may  be  necessary  to  withdraw  the  blades,  lest  their 
ends  should  cut  the  maternal  tissues,  reapplying  them  one  or 
more  times. 

Leverage  or  lateral  pendulum  movements  of  the  handles  have 
long  been  employed  by  those  who  have  used  the  long  or  short 
forceps  as  a  method  of  promoting  descent  of  the  head  in  difficult 
cases.  Even  in  expert  hands  it  is  not  without  risk,  especially  to 
the  fetal  tissues.  With  the  axis-traction  instrument  leverage  is 
absolutely  unnecessary. 

The  dynamic  action  implies  that  the  presence  of  the  instrument 
in  the  genital  passage  stimulates  the  uterus  to  activity.  Its  in- 
fluence is  sometimes  noted,  during  the  introduction  of  the  blades, 
to  such  an  extent  that  the  procedure  must  be  stopped  until  the 
pains  have  ceased.  When  traction  is  begun,  uterine  contraction 
also  may  be  induced. 

Application  and  Use  of  the  Forceps. — Preliminary  Con- 
siderations.— A  very  careful  examination  of  the  fetal  and  maternal 
parts  must  be  made.  It  is  not  sufficient  to  explore  and  measure 
the  pelvis  ;  the  size  and  position  of  the  fetal  head  must  be  care- 
fully estimated.  If  the  soft  or  hard  canal  be  too  small,  forceps 
will  be  useless  and  dangerous.  The  same  is  the  case  if  the  head 
be  too  large  and  hard,  macerated  or  perforated,  or  in  a  very  bad 
position.  The  fetus  should  be  alive  and  viable.  It  may  also  be 
extracted  when  dead  if  no  difficulty  exists  ;  in  the  latter  circum- 
stance embryulcia  should  be  substituted.  In  a  high  forceps  case 
the  head  may  be  above  the  brim  or  partly  engaged.  When  it  is 
freely  movable  above  the  brim,  an  assistant  should  push  it  into 
the  latter  by  pressure  applied  through  the  abdomen,  while  the 
operator  applies  the  blades.  The  cervix  must  be  fully  dilated, 
either  by  maternal  or  artificial  means.  The  membranes  must  be 
ruptured  and  retracted  upward,  so  that  they  shall  not  be  grasped 
by  the  blades. 

Preparation  for  the  Operation. — The  bladder  and  rectum 
should  be  well  emptied.  The  patient  should  be  anesthetized  with 
chloroform  or  ether ;  very  rarely  is  it  possible  to  operate  satis- 
factorily without  anesthesia.  The  patient  should  be  placed  in  the 
lithotomy  position  on  a  good  strong  table,  her  limbs  being  held 
up  by  assistants  or  by  leg-holders.  When  a  table  is  not  obtain- 
able, the  patient  may  be  placed  at  the  edge  of  the  bed,  which  is 


APPLICATION  AND    USE    OF   THE   FORCEPS. 


697 


protected  by  a  rubber  sheet  or  ring-pad.  In  Great  Britain  the 
left  lateral  position  has  long  been  employed  in  delivery,  and  the 
position  is  usually  termed  the  English  position.  The  author,  from 
an  ample  experience  of  both  postures,  has  no  hesitation  in  de- 
nouncing the  latter,  because  it  hampers  the  operator  in  his  manipu- 
lations, does  not  allow  the  employment  of  Walcher's  position,  and 
is  unfavorable  to  the  adoption  of  a  thorough  aseptic  technic, 
especially  when  the  patient  lies  in  bed.  All  that  can  be  said  in 
favor  of  the  English  position  is  that  there  is  less  exposure  of  the 
patient.  This,  however,  is  a  matter  of  no  importance  when  anes- 
thesia is  employed,  and  it  always  should  be  used. 

The  vulvar  hairs  should  be  shaved  or  closely  clipped,  and  the 


Fig.  305. — Patient  placed  on  edge  of  table  or  bed  (Bumm). 

genitalia  and  buttocks  should  be  cleansed  and  prepared  with  the 
same  thoroughness  observed  in  surgical  procedure.  The  parts 
surrounding  the  vulvar  slit  should  be  covered  with  sterile  cloths. 
The  operator  and  the  assistants  who  may  take  part  in  the  manipu- 
lations must  be  as  scrupulous  in  regard  to  the  preparation  of 
themselves,  the  instruments,  dressings,  etc.,  as  they  would  be  if  a 
surgical  operation  were  in  contemplation.  The  author  always 
wears  boiled  rubber  gloves  over  his  cleansed  hands,  and  has 
rarely  torn  them. 

Operation. — The  application  of  forceps  may  be  described  as 
the  high   operation  when  the  head  is  above  the  brim  or  partly 


698 


THE  FORCEPS. 


engaged  in  it,  and  as  the  low  operation  when  it  is  entirely  within 
the  pelvic  cavity.  Some  authorities  employ  the  latter  term  to 
apply  to  the  cases  in  which  the  head  is  at  the  vulva,  those  in 
which  it  lies  between  the  high  and  low  positions  being  termed 
inedimn.  The  high  operation  must  always  be  regarded  as  a  dif- 
ficult procedure,  requiring  much  skill  and  caution ;  the  low  opera- 
tion IS  a  simpler  procedure,  but  yet  not  without  risks. 


Fig.  306. — Application  of  axis-traction  forceps.     Introduction  of  first  or  left  blade. 

The  blades  should  always  be  applied  to  lie  right  and  left  in 
reference  to  the  maternal  pelvis,  the  fetal  head  being  grasped  as  it 
lies  in  relation  to  these  positions  of  the  blades.  Some  authors 
recommend  that  the  latter  may  be  applied  so  as  to  grasp  the  sides 
of  the  fetal  head,  no  matter  how  they  may  lie  in  relation  to  the 
pelvis.  This  teaching  is  unscientific  and  ridiculous,  and  in  prac- 
tice is   fraught  with  great  danger.      The  forceps  is   constructed 


APPLICATION  AND    USE    OF   THE   FORCEPS. 


699 


with  a  pelvic  curve,  which  allows  the  blades  to  lie  safely  only  in 
one  position — viz.,  right  and  left  as  regards  the  pelvis.  Of  course, 
it  is  better  to  grasp  the  head  transversely  than  obliquely  or  antero- 
posteriorly.  In  the  great  majority  of  low  applications  it  is  caught 
transversely.  In  most  high  operations  it  is  held  obliquely,  but 
experience  has  shown  that  with  the  axis-traction  forceps  this  grip 
is  .satisfactory  as  regards  delivery,  and  rarely  a  source  of  danger 


Fig.  307. ^Application  of  axis-traction  forceps.     Introduction  of  second  or  right  blade. 
The  shank  of  first  blade  rests  against  perineum. 


to  the  fetal  tissues.  Even  in  the  few  high  operations  (mainly  in 
flat  pelves)  in  which  the  head  has  been  grasped  anteroposteriorly, 
Murray  has  shown  that  considerable  compression  may  be  em- 
ployed without  hurting  the  fetal  head  or  without  producing  a 
detrimental  compensatory  bulging  in  the  transverse  diameter. 
I  do  not  refer  to  those  authors  who  employ  forceps  of  special 


700 


THE  FORCEPS. 


construction  in  order  to  grasp  the  head  transversely  in  all  circum- 
stances ;  they  fall  under  another  condemnation.  Their  efforts 
have  not  impressed  scientific  obstetricians,  praiseworthy  though 
they  may  be.  An  instrument  that  can  be  applied  safely  to  the 
sides  of  the  head  in  all  situations  in  the  pelvis,  so  that  traction 
maybe  exerted  without  the  expenditure  of  some  force  represented 
in  damage  to  fetal  and  maternal  tissues,  has  not  yet   been  con- 


FlG.  308. — Application  of  axis-traction  forceps.    Adjustment  of  lock  and  fixation  screw. 

structed.  The  application  of  the  axis-traction  forceps  so  that  the 
blades  are  right  and  left  as  regards  the  pelvis  in  every  condition 
of  the  head  in  which  forceps  is  indicated  is  the  nearest  approach 
to  the  highest  attainable  yet  devised. 

I.  High  Operation. — {a)  Introduction  of  the  Left  Blade. — The 
halves  of  the  instrument  and  the  traction  handle,  sterilized,  are 
placed  on  a  sterile   sheet,  conveniently  near  the  operator,  who 


APPLICATION  AND    USE    OF  THE  FORCEPS. 


701 


stands  or  sits  facing  the  perineum.  The  fingers  of  the  right  hand 
are  introduced  into  the  vagina  and  are  pushed  upward  between 
the  lower  part  of  the  head  and  the  maternal  tissues,  the  palmar 
surface  resting  against  the  former.  If  the  head  tends  to  move 
away  from  the  brim,  an  assistant  should  keep  it  in  position  by 
pressing  it  downward  through  the  abdominal  wall.  The  applica- 
tion handle  of  the  left  half  of  the  forceps  is  then  lifted  by  the 


Fig.  309.- 


-Application  of  axis-traction  forceps.     The  diagram  represents  beginning  of 
traction  in  a  case  in  which  the  head  is  at  inlet  of  pelvis. 


thumb  and  fingers  of  the  left  hand,  the  traction  rod  being  kept 
close  to  the  shank.  The  blade  is  then  introduced  downward  and 
backward  into  the  vagina,  the  tip  of  the  blade  pressing  against 
the  palmar  surface  of  the  right  hand.  As  it  is  passed  upward  it  is 
made  to  follow  the  curve  of  the  pelvis,  the  handle  being  gradually 
depressed  toward  the  perineum.     When  the   head  is  reached,  the 


702 


THE   FORCEPS. 


blade  must  be  cautiously  advanced  inside  the  fingers  until  it  rests 
in  position  against  the  head.  If  the  tip  is  obstructed,  it  must  not 
be  pushed  forcibly  onward,  lest  it  cause  tearing  (sometimes  a  fetal 
ear  may  be  lacerated  in  this  way),  but  must  be  slightly  withdrawn 
and  manipulated  past  the  obstruction.  If  a  uterine  contraction 
takes  place,  the  manipulations  must  cease  until  it  is  over.  When 
the  blade  lies  properly,  the  head  fits  nicely  within  the  cephalic 


MG.  310.- 


-Application  of  axis-traction  forceps.    Head  appearing  at  vulva.    Note  direc- 
tion of  traction. 


curve.    If  the  head  is  just  at  the  brim,  the  upper  end  of  the  handle 
is  a  short  distance  external  to  the  vulva. 

{B)  Introduction  of  the  Second  Blade. — When  the  first  blade  is 
in  position,  the  right  hand  is  withdrawn  from  the  vagina  and  made 
to  change  places  with  the  left  hand,  which  has  been  holding  the 
handle.     It  holds  this  half  of  the  forceps  in  position  while  the 


APPLICATION  AND    USE    OF   THE   FORCEPS. 


703 


left  hand  is  introduced  into  the  vagina  in  the  same  manner  in 
which  the  right  hand  was  introduced.  The  fingers  are  passed 
between  the  head  and  maternal  tissues,  their  dorsal  aspect  being 
directed  against  the  left  side  of  the  pelvis ;  the  head  is  then 
pressed  well  against  the  left  blade  of  the  forceps  in  order  to  keep 
it  in  position,  while  the  right  hand  is  removed  from  the  handle  to 
lift  the  right   half  of  the  forceps  and  introduce  it   in   a  manner 


Fig.  311. — Application  of  axis-traction  forceps.     Head  further  advanced  through  vulva. 

similar  to  that  described  for  the  first  blade,  the  traction  rod  being 
placed  well  forward  over  the  pubes.  This  procedure  is  sometimes 
difficult,  especiall)''  if  the  traction  rods  get  crossed.  To  prevent 
this  it  is  sometimes  advisable  that  an  assistant  hold  the  left  trac- 
tion rod  aside.  Great  patience  and  caution  are  necessary  at  this 
stage  of  the  manipulations. 

(r)  Fixing  of  the  Shanks  and  Adjustment  of  the  Traction  Rods. 


704 


THE  FORCEPS. 


— When  the  right  blade  is  in  position,  the  left  hand  is  withdrawn 
and  made  to  grasp  the  application  handle  of  the  left  half  If  the 
blades  He  properly,  the  halves  of  the  lock,  where  the  shanks  and 
handles  join,  are  laterally  directed,  being  exactly  opposite ;  by 
means  of  the  hands  on  the  handles  they  may  easily  be  made  to 
fit  together.  If  one  or  the  other  blade  has  slipped  from  its  proper 
position  (frequently  the  left  half  moves  somewhat  to  the  back 
while  the  second  half  is  being  introduced),  the  halves  of  the  lock 
will  not  fit  together,  and  it  is  necessary  to  manipulate  one  or  both 
handles  carefully  in  order  to  succeed.  The  locking  is  expedited 
by  depressing  the  handles  as  far  back  as  the  perineum  permits. 
Force  must  not  be  used.  Sometimes  it  is  necessary  to  withdraw 
one  or  both  blades  partially  or  entirely  and  to  replace  them  before 


Fig.  312. — Diagram  showing  right  and  wrong  methods  of  pulhng  on  handle  bar,  and 
that  the  line  of  traction  is  directly  in  axis  of  inlet  (much  modified  from  Ribemont). 

locking  is  finished.  If  the  head  be  well  within  the  cephalic  curve, 
in  case  of  a  transverse  or  slightly  oblique  grasp,  the  handles  are 
not  far  apart  when  locked  ;  if  the  head  be  large  or  be  grasped 
anteroposteriorly,  they  may  lie  considerably  apart.  In  bringing 
the  shanks  together  the  vulva  must  not  be  pinched.  One  hand 
now  grasps  the  locked  handles  while  the  other  moves  the  traction 
rods  behind  the  shanks.  The  fixation  screw  is  then  adapted  but 
not  tightened  on  the  application  handles.  The  traction  rods  are 
then  locked  and  the  traction  handle  applied.     The  fingers  of  one 


APPLICATION  AND    USE    OF   THE    FORCEPS. 


70s 


hand  are  then  introduced  to  feel  that  the  blades  are  properly  ap- 
plied and  do  not  grasp  the  umbilical  cord  or  any  part  of  the 
maternal  tissues — e.  g.,  the  cervix.  The  fixation  screw  is  then 
turned  sufficiently  to  insure  that  the  blades  will  not  slip  from  the 
head. 

{d)  Extraction. — The  operator  places  himself  so  as  to  pull 
most  efficiently  without  disturbing  the  appUcation  handles.  Trac- 
tion is  made  with  the  traction  handles,  the  middle  parts  of  the 
rods  being  kept  parallel  with  the  shanks.  Force  is  applied  during 
uterine  contractions,  but  if  these  be  absent,  then  at  intervals  of 


Fig.  313. — Diagram  representing  axis-traction  forceps  in  successive  stages  of  delivery. 
Tiie  application  was  made  to  head  lying  within  pelvic  cavity. 


one  or  two  minutes,  and  lasting  for  a  minute.  After  each  pull 
the  fixation  screw  should  be  loosened  in  order  to  release  the  head 
from  pressure.  Frequent  examination  should  be  made  to  deter- 
mine the  advance  made  by  the  head  and  the  condition  of  the 
maternal  parts.  The  rate  and  force  of  the  fetal  heart  should  be 
determined  by  auscultation  from  time  to  time.  Usually  traction  is 
exerted  with  one  hand,  though  sometimes  it  is  necessary  to  use 
both.  Where  rotation  has  to  be  assisted  (this  is  rare),  rectification 
may  be  made  by  means  of  the  application  handles.    When  marked 


7o6 


THE   FORCEPS. 


rotation  occurs,  so  that  the  maternal  tissues  are  endangered  by  the 
tips  of  the  blades,  the  forceps  must  be  removed  and  reapplied 
again  laterally  as  regards  the  pelvis.  As  the  head  approaches 
the  perineum,  the  latter  should  be  covered  with  a  sterile  towel, 
the  left  hand  being  used  to  guard  it  in  the  manner  described  for 
normal  labor.  The  legs  should  then  be  lowered  from  the  lithotomy 
position  and  allowed  to  hang  over  the  end  of  the  table,  in  the 
manner  recommended  by  Walcher,  and  held  somewhat  apart  by 
assistants.  (When  the  latter  are  not  available,  the  legs  may  be 
kept  apart  by  the  body  of  the  operator  as  he  stands  or  sits  be- 
tween them.)  In  this  position  the  perineum  is  most  relaxed,  and, 
therefore,  less  liable  to  be  torn,  than  it  is  when  the  thighs  are  bent 
up  in  the  lithotomy  position.     As  the  head  is  extracted  from  the 

outlet,  traction  should  be  kept  up  by 
means  of  the  traction  handles,  for  in 
this  way  can  the  best  direction  be 
taken  and  the  natural  m.echanism  be 
most  closely  imitated.  During  the  birth 
of  the  head  the  application  handles  may 
point  well  up  over  the  pubes.  (The  ad- 
vice of  some  authorities,  to  the  effect 
that  at  this  stage  the  application  handles 
should  be  grasped  and  used  as  a  pair  of 
long  forceps,  has  already  been  noted 
and  condemned.)  The  head  should  be 
delivered  very  slowly  and  gradually. 
If  labor  pains  are  strong  at  this  period, 
they  should  be  allowed  to  advance  the 
head  as  much  as  possible.  Sometimes 
it  is  necessary  to  perform  episiotomy,  in 
order  to  save  a  mesial  tear  of  the  peri- 
neum. As  soon  as  the  head  is  born 
the  traction  rods  are  separated,  the 
fixation  screw  loosened,  and  the  blades 
successively  removed. 

II.  Lozv  Operation. — The  application 
of  the  axis-traction  forceps  when  the  head  is  at  a  medium  or 
low  level  in  the  pelvis  is  much  simpler  than  the  procedure 
just  described.  The  instrument  is  used  in  practically  the  same 
manner.  Many  authorities  discard  the  axis-traction  instrument 
for  these  cases  and  use  the  long  forceps  instead,  recommend- 
ing the  former  only  for  the  high  operation.  This  attitude  is  unsci- 
entific. If  one  instrument  is  suitable  for  all  cases,  it  is  useless  to 
carry  two.  If  the  same  instrument  is  the  best  in  every  circum- 
stance, it  is  wrong  to  use  the  poor  forceps  except  when  the  good 
one  cannot  be  obtained.  The  axis-traction  forceps  needs  only  to 
be  known  to  be  appreciated,  but  requires  to  be  studied  in  order  to 


Fig.  314. — Misuse  of  axis- 
traction  forceps  at  perineum 
(after  PouUet,  etc.).  Complete 
delivery  of  head  should  be 
effected  bv  means  of  traction 
handle  onl\  (Milne  Murray). 


APPLICATION  AND    USE    OF   THE   FORCEPS. 


707 


be  understood.  Its  principle  is  very  simple,  and  a  knowledge  of 
its  working  easily  acquired  by  a  little  practice  with  a  manikin.  If 
it  be  adopted,  the  old  short  and  long  forceps  may  be  relegated  to 
museum  shelves. 

Use  of  Long  Forceps. — For  the  sake  of  those  who  may  be 
called  upon  to  use  a  pair  of  long  forceps  a  few  words  may  be  .said 
reeardine  the  use  of  the  instrument.  The  blades  are  introduced 
in  the  manner  already  described  for  the  blades  of  the  axis-traction 
forceps.  To  keep  them  applied  to  the  head  a  certain  amount  of 
compression  of  the  handles  must  be  kept  up  by  one  hand.  This 
should  not  be  excessive,  but  it  is  very  difficult  to  regulate  the 
grasp  of  the  fingers  to  a  nicety  while  traction  is  made,  and  therein 


^% 

\ 

/ 

>^ 

,^^-r—    _  y 

'^; 

-——^5^ 

i 

«\-A'^^ 

\ 

/■ 

/ 

1 

/ 

K 

.^    . 

^ 

_^^  -  -  ~-'-^^^^^^' 

~~^* 

Fig.  315. — Introduction  of  first  blade  of  long  forceps,  head  being  low  in  pelvis. 

lies  one  great  objection  to  the  instrument.  In  pulling  both  hands 
generally  require  to  be  used,  the  fingers  of  one  hand  being  placed 
on  the  cross-bars,  attached  to  the  handles  near  the  shanks  in 
English  and  German  forceps,  or  at  the  ends  of  the  handles  in 
French  forceps.  If  direct  traction  is  made,  much  of  the  force  is 
lost,  especially  in  the  high  operation,  and  the  head  is  pressed 
unduly  against  the  maternal  tissues.  Consequently  it  is  best  to 
pull  in  such  a  way  as  to  make  the  head  move  along  the  curved 
canal  with  as  little  loss  of  power  as  possible.  Pajot's  maneuver  is 
generally  used  for  this  purpose,  as  follows  :  One  hand  holds  the 
handles,  the  other  the  shanks  ;  the  former  pulls  downward,  the 


7o8 


THE   FORCEPS. 


Other  backward.  This  maneuver  may  be  carried  out  by  the 
operator  in  the  sitting  or  standing  posture.  The  impossibility  of 
combining  these  two  forces  so  that  the  proper  direction  is  given 
to  the  head  without  considerable  waste  of  force,  has  already  been 
explained.  This  constitutes  the  great  inferiority  of  the  long  forceps 
to  the  axis-traction  forceps. 

Dangers  of  Forceps. — In  introducing  the  blades  the  vagina 
or  uterus  may  be  bruised  or  torn  to  a  slight  or  a  marked  extent. 
The  risk  of  injuring  the  uterus  is  great  when  the  cervix  is  closely 
applied  to  the  head  or  during  a  period  of  contraction.     Hemor- 


FlG.  316. — Beginning  application  of  the  second  blade.    The  handle  follows  direction  of 

arrow  to  reach  position  shown  faintly  near  first  blade  in  place. 

rhage  may  thus  be  caused  before  as  well  as  after  delivery.  The 
bladder,  rectum,  or  peritoneum  may  sometimes  be  opened.  The 
fetu"  may  also  be  injured  during  the  introduction.  The  soft  parts 
may  be  contused  or  cut.  In  extraction  the  cervix  may  be  torn 
if  it  has  been  caught  between  the  blades  and  the  head.  The  walls 
of  the  passage  may  be  cut  by  the  tips  of  the  blades  if  they  have 
been  badly  applied  or  if  they  are  displaced.  Injury  may  be  done 
by  the  sudden  slipping  of  the  blades  from  the  head.     In  misdirected 


APPLICATION  AND    USE    OF   THE   FORCEPS. 


709 


traction  the  maternal  tissues  may  be  badly  bruised  by  compression 
against  the  bony  pelvis.  If  traction  be  too  forcible,  the  same  result 
may  be  produced.  The  strength  of  the  pull  should  rarely  be 
more  than  25  or  30  pounds.  Very  frequently  open  tears  and  cuts 
are  produced — i\  g-.,  perineal  lacerations.  It  must,  however,  be 
remembered  that  important 
structures  may  be  stretched  or 
divided,  though  no  surface 
wound  is  produced,  and  may 
be  the  cause  of  much  discom- 
fort and  trouble  afterward. 
The  fetus  may  also  be  injured 
during  extraction.  Contusion 
or  laceration  of  the  soft  parts, 
often  associated  with  subcu- 
taneous blood-extravasation, 
may  result.  Nerves  may  be 
injured — e.  g.,  facial  and  bra- 
chial plexus — and  may  not  re- 
cover their  function  for  a  long 
time.  The  head  bones  may 
be  fractured  and  may  be 
associated  with  intracranial 
or  extracranial  hemorrhage. 
Blood  may  also  be  extrava- 
sated  inside  the  skull  with- 
out bone  fracture.  The  an- 
tero-inferior  corner  of  the  pa- 
rietal bone  is  especially  apt  to 
be  broken. 

The  fetus  may  thus  be  destroyed,  or  its  health  may  be  im- 
paired for  a  considerable  period  after  birth.  It  is  believed 
by  many  that  epilepsy,  psychic  disturbances,  idiocy,  and  other 
lesions  may  in  some  cases  be  traced  to  instrumental  delivery.  If 
the  umbilical  cord  be  around  the  neck,  it  may  be  caught  and  the 
fetus  be  asphyxiated.  Asphyxia  may  also  be  produced  by  the 
compression  of  the  brain  tissue.  Too  rapid  extraction  may  cause 
inertia  uteri  with  its  attendant  complications. 


Fig.  317. — Upward  traction  when  occi- 
put has  passed  pubic  arch  and  pelvic  floor 
is  on  stretch. 


7IO  CESAREAN  SECTION. 

CHAPTER    IV. 
CAESAREAN  SECTION. 

The  Caesarean  section,  properly  so  called,  is  the  extraction  of 
the  fetus  from  the  uterus  by  means  of  an  abdominal  incision.  The 
term  conservative  CcBsarea?i  section  is  applied  to  the  procedure  in 
which  the  uterus  is  left  after  removal  of  the  fetus,  placenta,  and 
membranes. 

Porro's  operation  is  that  in  which,  after  the  extraction  of  the 
fetus,  supravaginal  amputation  of  the  uterus  is  carried  out.  Total 
abdominal  hysterectomy  is  also  sometimes  employed  after  removal 
of  the  fetus. 

Historic. — Though  Caesarean  section  is  believed  to  have  been 
known  in  veiy  ancient  times,  we  have  no  certain  knowledge  as  to 
its  employment.  There  is  no  foundation  for  the  statement  that 
the  operation  was  named  after  the  first  Caesar,  in  memory  of  the 
manner  in  which  he  came  into  the  world.  The  term  is  probably 
derived  from  ccedere,  to  cut.  It  is  not  unlikely  that  the  operation 
was  known  long  before  the  time  of  Julius  Caesar.  In  the  Middle 
Ages  the  Church  urged  that  the  operation  should  be  performed 
on  a  woman  who  died  in  adv^anced  gestation,  in  order  that  the 
fetus  should  be  baptized  before  it  died.  The  first  certain  record 
of  a  Caesarean  section  performed  successfully  is  that  referring  to  a 
Swiss  pig-gelder,  Jacob  Nufer,  who  operated  on  his  own  wife  in 
the  year  1500. 

In  Germany  it  was  first  performed  by  Trautmann,  of  Wit- 
tenberg, in  16 10;  the  patient  lived  for  three  weeks.  In  1581 
F.  Rousset  published  the  histories  of  9  successful  operations  that 
were  reported  to  him  from  various  sources.  Several  critics  have 
considered  tliese  as  doubtful,  and  some  have  supposed  that  the 
cases  were  ectopic  gestations  in  which  extraction  of  the  fetus  was 
carried  out  through  the  abdominal  wall.  Up  to  the  time  of 
Mauriceau  the  incision  was  made  on  the  lateral  abdominal  wall ; 
this  surgeon  first  advised  that  it  be  made  in  the  middle  line. 
When  symphysiotomy  was  introduced  by  Sigault,  in  1777,  the 
Caesarean  operation  was  decried  by  many,  but  it  continued  to  be 
practised,  the  other  procedure  soon  being  forgotten.  Lebas  is 
said  to  have  sutured  the  uterine  incision  first — in  1769.  He  was 
criticized  by  Smellie,  Levret,  and  later  by  Baudelocque,  Velpeau, 
and  other  distinguished  authorities.  They  preferred  the  old  plan 
of  introducing  no  sutures,  trusting  to  uterine  contractions  to  ap- 
proximate the  edges  of  the  incision.  Others  tried  to  introduce 
the  suture,  but  without  avail.  In  1859  Lestocquoy  recommended 
stitching  the  uterine  wound  to  the  abdominal  incision. 

Up  to   the   antiseptic   period   the   mortality  of  the  Caesarean 


HISTORIC.  711 

operation  was  very  high,  the  women  dying  generally  of  sepsis  or 
hemorrhage.  Michaehs,  in  1822,  collected  258  cases,  with  54  per 
cent,  of  recoveries;  Mayer,  in  1868,  gathered  1605  cases,  with 
the  same  percentage;  Harris,  in  1888,  tabulated  153  cases  from 
American  literature,  with  37  per  cent,  of  recoveries.  Indeed, 
throughout  the  civiUzed  world,  during  the  first  three-quarters  of 
the  nineteenth  century,  embryotomy  was  universally  practised  in 
preference  to  the  Caesarean  operation.  With  the  introduction  of 
antiseptic  surgery  the  operation  entered  on  a  new  era.  The  fol- 
lowing table  compiled  by  Williams  reveals  the  progress  that  has 
been  made  : 

Operators.                                                                                         Cases.  Deaths. 

Zweifel     .    .        76  i 

Olshausen 30  2 

Reynolds      .    -        23  O 

Bar 14  I 

Charles 10  O 

Craigin 9  I 

Total 162  5 

Per  cent 3.0S 

Larger  tables  have  been  compiled  by  Braun,  Bar,  and  Wil- 
liams, giving  a  mortality  between  6  and  7  per  cent.,  but  if  the 
deaths  of  those  women  who  were  infected  before  operation  be 
excluded,  the  mortality  is  about  4  per  cent.  It  may  safely  be  said 
that  if  the  operation  be  performed  by  skilled  hands,  when  the 
patient  is  not  exhausted  and  not  infected,  the  mortality  is  3  to  4 
per  cent. ;  Braun  and  Bar  state  that  the  fetal  mortality  in  all  cases 
is  about  5.7  per  cent.  In  the  hands  of  unskilled  operators  or  of 
those  whose  technic  is  not  perfect,  the  mortality  may  be  expected 
to  amount  to  more  than  20  per  cent.  In  the  hands  of  the  latter 
the  risks  are  greatly  increased  by  careless  and  unnecessary  vaginal 
examinations,  attempts  at  delivery,  and  protracted  delay. 

In  1876  Porro  introduced  supravaginal  amputation  of  the 
uterus,  after  removal  of  the  fetus,  at  the  Maternity  in  Pavia.  He 
did  this  in  order  to  diminish  the  chances  of  hemorrhage  and 
sepsis,  and  he  referred  particularly  to  the  bad  practice  of  leaving 
the  uterine  incision  unsutured.  For  several  years  Porro's  opera- 
tion was  widely  practised,  though  for  a  considerable  time  the 
mortality  was  little  better  than  that  of  the  old  Cesarean  operation. 
In  1884  Godson  collected  a  list  of  152  cases,  with  a  mortality  of 
56.57  per  cent.  R.  Braun  and  Demelin  give  statistics  showing 
that  the  mortality  for  all  cases  has  been  in  recent  years  9  to  10 
per  cent.  If  the  deaths  due  to  infection  previous  to  operation 
be  excluded,  the  percentage  may  be  considerably  reduced.  Several 
operators  returned  to  the  old  operation,  which  R.  Harris,  of 
America,  showed  was  safer  when  it  was  not  too  long  delayed. 
Reuss  and  others  stated  that  under  the  antiseptic  system  the 
uterine  wall  could  be  safely  sutured. 


712  CESAREAN  SECTION. 

It  is  to  Sanger,  however,  that  credit  is  chiefly  due  for  the  im- 
proved technic  of  Caesarean  section  at  the  present  time.  In  his 
paper,  written  in  1882,  he  showed  that  the  old  plan  of  leaving  the 
uterine  incision  open  was  dangerous,  not  only  because  of  the  op- 
portunity it  afforded  for  the  passage  of  material  from  the  uterus 
into  the  peritoneal  cavity,  but  also  because  when  healing  did  take 
place  it  resulted  usually  in  an  irregular  cicatrix,  which  was  prone 
to  rupture  or  to  form  hernial  protrusions  ;  if  complete  healing 
did  not  occur,  fistulous  openings  were  left.  Sanger  insisted  upon 
suturing  the  wall  under  an  antiseptic  technic,  and  urged  that  the 
operation  should  not  be  prolonged  too  long.  About  the  same 
time  Kehrer,  of  Heidelberg,  advocated  the  same  views.  Sanger 
recommended  two  layers  of  sutures  in  closing  the  uterine  wound  : 
one  for  the  musculature,  the  other  for  the  peritoneum.  In  recent 
years  the  conservative  operation  has  come  more  into  prominence, 
and  the  Porro  operation  has  been  restricted  within  comparatively 
narrow  limits. 

Conservative  Caesarean  Section. — Indications. — These 
are  absolute  in  all  cases  in  which  the  fetus,  living  or  broken  up, 
cannot  be  delivered  by  the  genital  passage,  and  relative  when 
there  is  a  choice  between  the  Caesarean  operation  and  symphysi- 
otomy, embryotomy,  or  the  induction  of  premature  labor. 

Owing  to  the  great  reduction  in  the  death-rate  of  Caesarean 
section  (3  to  4  per  cent,  in  cases  in  which  no  infection  is  present 
at  the  time  of  operation),  it  must  take  a  more  prominent  place  in 
the  practice  of  skilled  operators  than  it  has  in  the  past.  It  is 
probably  as  safe  for  the  mother  as  is  embiyotomy,  and  has  the 
advantage  of  saving  the  fetus  in  the  great  majority  of  cases. 
Pinard  has  reported  a  maternal  mortality  of  11.5  per  cent,  in  81 
embryotomies,  some  of  the  deaths,  however,  being  due  to  trauma 
and  sepsis  resulting  from  manipulations  of  practitioners  before 
admission  to  his  service.  Premature  labor,  while  being  safe  for 
the  mother,  is  fatal  to  the  fetus  in  a  considerable  percentage  of 
cases.  It  has  been  widely  taught  that  an  absolute  indication  for 
Caesarean  section  is  a  conjugata  vera  of  5.5  cm.  Williams  has 
rightly  urged  that  this  should  be  raised  to  7  cm.  With  regard  to 
the  relative  indication,  he  holds  that  the  upper  limit  should  be  8.5 
cm.  for  flat  and  9  cm.  for  justominor  pelves,  thereby  placing  the 
operation  in  competition  with  high  forceps  and  version  in  those 
cases  of  moderate  contraction  in  which  the  head  does  not  tend  to 
engage  in  the  brim,  instead  of  making  it  a  rival  of  craniotomy 
upon  the  living  child,  as  with  the  old  relative  indication  of  7  or 
7.5  cm.  It  is  not  always  possible  to  state  what  may  happen  in 
such  cases,  for,  while  the  pelvic  contraction  may  be  ascertained, 
the  size  and  plasticity  of  the  head  and  the  strength  of  the  uterine 
pains  cannot  be  accurately  determined.  Spontaneous  delivery 
occurs  in  a  considerable  number  of  these  cases  ;  in  Williams's 


CONSERVATIVE    CESAREAN  SECTION.  /1 3 

experience  it  took  place  in  one-third  of  the  cases  in  which  the 
brim  measured  between  7  and  8  cm.,  and  in  two-thirds  of 
those  in  which  it  measured  between  8  and  9  cm.  This  author, 
therefore,  recommends  that  in  deahng  with  this  class  of  pelves 
labor  should  be  allowed  to  go  on  until  the  second  stage  has  lasted 
an  hour.  If  by  that  time  the  head  has  engaged,  labor  should 
continue,  forceps  being  employed  if  there  be  undue  delay.  If 
the  head  does  not  engage,  Caesarean  section  should  be  carried 
out  if  the  circumstances  are  favorable  for  the  performance  of  a 
major  operation,  if  the  woman  be  uninfected  and  in  good  condi- 
tion, and  the  child  be  alive. 

Williams  thinks  that  the  treatment  of  such  cases  by  forceps  or 
version  should  disappear,  Caesarean  section  promising  a  great 
diminution  in  fetal  mortality  without  appreciably  raising  the 
maternal  mortality.  These  views  are  likely  to  meet  with  marked 
opposition.  Those  who  are  experts  in  the  use  of  the  best  forms 
of  axis-traction  forceps  will  claim  that  this  instrument  may  be 
safely  used  both  for  mother  and  fetus  in  flat  pelves  with  a  con- 
jugate as  low  as  7.5  cm.  (3  in.)  if  the  head  be  normal,  especially 
where  the  Walcher  position  is  used.  They  would  urge  that  in 
some  of  the  non-engagement  cases  the  head  might  enter  the  brim 
if  the  patient  were  placed  in  Walcher's  position.  Most  of  all 
might  they  be  expected  to  oppose  the  abandonment  of  axis- 
traction  forceps  in  flat  pelves  with  a  conjugate  of  8.5  cm.,  and  in 
justominor  pelves  with  one  of  9  cm.  Exponents  of  the  value 
of  version  would  equally  strongly  plead  for  this  operation  in  flat 
pelves  with  a  conjugate  in  the  neighborhood  of  8.5  cm.  Advo- 
cates of  symphysiotomy  would  urge  that  in  the  best  hands  the 
operation  is  as  favorable  for  the  mother  as  Caesarean  section  when 
the  conjugate  is  above  7  cm.  in  flat  pelves,  though  the  fetal  mor- 
tality may  be  greater.  Others  would  agree  with  Kronig  in  urging 
that  Caesarean  section  should  not  be  performed  for  the  relative 
indication  after  rupture  of  the  membranes,  but  that  symphysiotomy 
is  then  indicated. 

Experience  shows  that  section  performed  late  in  labor  subjects 
the  woman  to  more  risks  than  one  carried  out  early.  While  in 
most  cases  the  woman's  chances  of  safety  might  not  be  lessened 
by  operating  one  hour  after  the  beginning  of  the  second  stage,  it 
is  certain  that  she  would  not  be  in  so  satisfactory  a  general  con- 
dition as  if  labor  had  not  proceeded  far.  Moreover,  if  the  first 
stage  were  very  tedious,  Williams's  limit  might  mean  a  consider- 
able addition  of  risk. 

Williams's  indications  are  meant  only  for  those  who  are  within 
the  reach  of  expert  obstetricians  and  operators.  For  those  not 
so  favorably  placed  he  recommends  the  old  indications.  There  is 
much  to  be  said  in  favor  of  his  views,  which  are  based  upon  two 
factors — viz.,  the  low  maternal  mortality  in  Caesarean  section  per- 


714  CESAREAN  SECTION. 

formed  under  favorable  circumstances,  and  the  desire  to  lower 
the  fetal  death-rate.  There  is  no  doubt  that  he  is  too  sweep- 
ing in  his  condemnation  of  forceps  in  the  class  of  cases  under 
consideration.  He  is  right  if  he  refers  to  long  forceps,  but  wrong 
if  he  means  the  best  scientifically  constructed  axis-traction  forceps 
— e.  g.,  those  of  Milne  Murray.  While  admitting  that  the  fetal 
mortality  is  higher  when  this  instrument  is  used  than  in  Caesar- 
€an  section,  the  author  has  yet  to  witness  a  maternal  death 
produced  by  it  in  the  hands  of  a  skilled  operator.  Williams's 
indications  are  not  likely  to  find  wide  acceptance,  owing  to  the 
widespread  tendency  to  regard  the  life  of  the  fetus  as  secondary  in 
importance  to  that  of  the  mother,  and  to  the  general  preference 
of  husbands  to  sacrifice  the  former  rather  than  hazard  the  latter. 
Were  they  to  be  widely  adopted,  the  result  would  inevitably  be 
that  those  who  are  not  trained  in  the  technic  of  asepsis  and  are 
incompetent  to  undertake  the  Caesarean  operation  would  do  so 
under  all  circumstances,  including  those  which  are  likely  to  intro- 
duce infection,  such  as  frequent  examination  and  injudicious  at- 
tempts at  deliver}^  Moreover,  operators  who  are  skilled  in  the 
use  of  axis-traction  forceps  and  in  version  will  always  be  inclined 
to  adopt  their  favorite  measure,  knowing  that  the  fetus  may  be 
alive  and  that  there  is  little  chance  that  the  mother  will  die.  If 
these  procedures  fail,  they  know  that  embryotomy  yet  remains  to 
be  tried.  Probabh^  the  chief  argument  in  favor  of  Williams's 
indications  is  a  moral  one.  Those  who  regard  the  life  of  the 
fetus  as  important  as  that  of  the  mother  will  be  inclined  to  adopt 
them. 

Caesarean  section  is  indicated  in  cases  in  which  the  outlet  of 
the  bony  pelvis  is  so  contracted  that  delivery  with  forceps  is  im- 
possible, though  it  may  sometimes  be  considered  as  an  alternative  n 
to  embryotomy.  It  is  also  indicated  when  tumors  of  the  bone  or 
soft  parts,  or  cicatrization  of  the  vagina,  greatly  diminish  the 
parturient  canal.  In  cases  of  marked  displacement  of  the  cer- 
vix following  vaginal  or  ventrofixation  previous  to  pregnancy, 
Caesarean  section  may  be  necessary.  It  is  rarely  indicated  in 
.some  cases  of  accidental  hemorrhage.  Recently  it  has  been 
recommended  in  some  cases  of  eclampsia  and  placenta  praevia. 
For  the  former  condition  Halbertsma  proposed  the  operation  in 
1878.  Hillmann  has  recently  reported  39  cases,  with  a  maternal 
mortality  of  51.3  per  cent,  and  a  fetal  mortality  of  43.9  per  cent. 
The  operation  should  not  be  performed  in  eclampsia  unless  some 
positive  indication  exists — e.  g.,  contraction  of  the  birth  canal. 
When,  also,  an  eclamptic  dies,  the  fetus  being  still  alive  ///  iitcro,  it 
is  the  duty  of  a  physician  who  may  be  present  at  the  time  of 
birth  to  advise  immediate  postmortem  Caesarean  section.  Bauer 
has  recently  reported  8  such  cases,  in  which  4  infants  were  saved. 
It  may  be  performed  on  a  woman  who  dies  in  advanced  preg- 


CONSERVATIVE   CMSAREAN  SECTION.  715 

nancy,  in  the  hope  of  saving  the  fetus.  It  should  not  be  carried 
out  when  the  fetus  is  dead,  save  when  the  absolute  indication 
exists.  It  should  not  be  performed  when  labor  has  been  long  in 
progress,  after  repeated  attempts  at  delivery  have  been  made,  if 
the  mother  is  exhausted  or  has  been  subjected  to  the  chance  of 
infection,  unless  there  is  an  absolute  indication.  Under  such  con- 
ditions the  mortality  of  Caesarean  section  is  high,  and  symphysi- 
otomy or  embryotomy  or  both  should  be  employed.  Caesarean 
section  has  been  rarely  employed  where  the  diagnosis  of  mon- 
strosity has  been  made,  the  latter  being  of  such  a  nature  as  to 
imperil  the  mother's  life  by  delivery  through  the  maternal  passage. 

The  importance  of  the  careful  examination  and  measurement 
of  pregnant  women  cannot  be  too  highly  urged.  Were  this 
advice  always  followed,  it  would  be  possible  to  decide  as  to  the 
future  treatment  after  more  thorough  consideration  than  is  pos- 
sible when  a  sudden  choice  has  to  be  made.  Arrangements  could 
be  more  satisfactorily  made  and  the  patient  more  considerately 
treated.  Nevertheless,  in  certain  cases  it  is  impossible  to  decide 
that  a  Caesarean  section  is  necessary  until  labor  has  begun. 

Time  of  Operation. — There  is  a  difference  of  opinion  as  to 
when  the  operation  should  be  performed  in  cases  in  which  a 
choice  can  be  made.  When  the  absolute  indication  exists,  it  is 
generally  believed  that  the  most  favorable  period  is  immediately 
after  labor  has  begun,  because  the  uterus  is  likely  to  contract  well 
after  being  emptied.  Others  hold  that  it  is  not  necessary  to  wait 
for  labor,  the  uterus  being  certain  to  contract  and  retract  well  if 
emptied  before  labor  starts.  It  has  been  well  established  that  actual 
labor  pains  are  not  necessary  to  prevent  uterine  inertia  and  hem- 
orrhage. Uterine  contractions  take  place  throughout  pregnancy, 
though  painlessly,  and  the  removal  of  the  uterine  contents  is  a 
certain  stimulus.  Those  who  operate  after  labor  has  commenced 
think  that  an  advantage  is  gained  in  having  a  partly  dilated  cervix 
through  which  drainage  may  be  established.  It  is,  however,  easy 
to  dilate  the  cervix  sufficiently  to  pass  a  piece  of  gauze  into  the 
vagina. 

There  is  an  advantage  in  selecting  the  hour  of  operation — viz., 
that  it  can  be  arranged  during  the  day,  at  the  most  convenient 
time.  In  cases  in  which  the  relative  indication  for  the  operation 
exists,  it  may  frequently  be  necessary  to  wait  until  labor  has 
progressed  even  into  the  second  stage.  The  woman  should  not 
be  allowed  to  wait  until  she  is  exhausted,  because  the  chances  of 
success  are  thereby  greatly  diminished. 

Operation. — All  preparations  are  made  as  for  any  abdominal 
section,  the  strictest  technic  being  observed.  The  vagina  should 
be  thoroughly  sterilized.  The  incision  is  made  mesially  above  the 
pubes,  the  length  varying  according  to  whether  or  not  the  preg- 
nant uterus  is  to  be  lifted   through  it.       In  the  former  case  it 


7l6  CESAREAN  SECTION. 

should  be  about  8  in.,  and  in  the  latter  5  in.,  in  length.  The  author 
favors  the  long  incision,  in  order  that  the  uterus  may  be  lifted 
through  it ;  in  this  way  it  may  be  kept  under  good  control  and 
it  is  easier  to  prevent  the  entrance  of  fluids  into  the  peritoneal 
cavity.  Against  the  long  incision  is  the  extensive  scar  that  is 
caused.  This  is  not  important,  and  need  not  favor  hernia  if  the 
wound  be  stitched  properly.  In  such  cases  the  navel  should  be 
excised  and  the  edges  of  the  recti  exposed  in  the  entire  length  of 
the  incision  before  closure  is  made.  Zweifel's  objection,  that  a 
greater  extent  of  adhesions  is  likely  to  occur  after  a  long  incision, 
is  trivial.  If  the  peritoneum  be  properly  stitched  both  on  the 
uterine  and  abdominal  walls — /.  c,  be  inverted  on  the  former  and 
everted  on  the  latter — by  a  continuous  catgut  suture,  and  an 
aseptic  technic  be  observed,  no  adhesions  will  follow. 

After  the  long  incision  is  made  the  uterus  is  carefully  lifted 
through  it  and  surrounded  with  towels  soaked  in  hot  normal 
saline  solution.  The  peritoneal  cavity  is  then  packed  with  hot 
pads  above  the  uterus,  and  the  abdominal  incision  temporarily 
closed  over  them  with  a  single  through-and-through  temporary 
suture.  In  this  way  the  peritoneum  is  protected  from  contamina- 
tion by  blood  and  liquor  amnii. 

Uterine  Incision. — Various  uterine  incisions  have  been  recom- 
mended— /.  c.,  sagittal  fundal,  low  transverse,  anterior  longitudinal, 
posterior  longitudinal,  and  lateral.  Fritsch,  in  1897,  introduced 
the  transverse  fundal  incision.  He  believes  that  by  this  method  the 
placenta  is  less  frequently  cut  down  upon  ;  there  is  less  bleeding ; 
there  is  greater  diminution  of  the  wound,  and  less  stitching  is 
required  ;  the  child  can  be  more  easily  extracted  ;  the  escape  of 
blood  and  liquor  amnii  into  the  peritoneal  cavity  can  be  better 
prevented  ;  there  is  less  risk  of  after-hernia,  because  the  abdomen 
can  be  opened  higher  up.  These  statements  of  Fritsch  are 
marked  exaggerations  and  cannot  be  upheld  by  those  who  con- 
sider the  subject  dispassionately.  The  results  obtained  by  the 
transverse  fundal  incision  are  in  no  degree  better  than  those  ob- 
tained by  the  mesial  incision  through  the  fundus  and  anterior 
uterine  wall. 

Some  recommend  that  the  placenta  should  never  be  divided, 
because  of  the  greater  loss  of  blood.  This  also  is  unnecessary 
advice.  It  is  usually  most  convenient  to  make  the  incision 
mesially  from  the  fundus  downward  for  5  in.  Olshausen  first 
incises  the  fundus  and  then  carries  the  incision  anteriorly  or  pos- 
teriorly, according  to  the  position  of  the  placenta,  which  he  tries 
to  avoid.  As  the  wall  is  divided  opened  vessels  may  be  caught 
with  forceps,  but  usually  the  pressure  of  an  assistant's  hands  on 
each  side  of  the  incision  is  sufficient  to  check  bleeding.  When 
the  membranes  are  reached,  they  bulge  into  the  opening,  appearing 
dark-colored.     An  opening  is  made  into  them   and  rapidly  en- 


CONSERVATIVE    C CESAREAN  SECTION.  'Jl'J 

larged.  If  the  placenta  is  on  the  anterior  wall,  it  should  be  divided 
without  hesitation.  The  loss  of  blood  need  not  be  great  and  will 
not  harm  the  fetus. 

The  assistant  may  now  compress  both  broad  ligaments  with 
his  hands,  while  the  operator  passes  his  hands  into  the  amniotic 
sac,  near  the  fundus,  and  grasps  the  fetus  by  a  leg  or  buttock. 
If  the  head  is  uppermost,  it  may  be  grasped  with  both  hands  and 
delivered.  If  there  is  much  resistance,  the  incision  may  be  sUghtly 
enlarged.  During  the  delivery  the  liquor  amnii  escapes  freely. 
The  cord  is  then  clamped  near  the  fetus  and  divided,  the  fetus 
beincr  mven  to  an  assistant  for  resuscitation. 

Soon  after  the  removal  of  the  fetus  the  uterus  diminishes  in 
size,  its  wall  thickening.  The  hand  should  be  immediately  intro- 
duced into  its  cavity  in  order  to  peel  off  the  placenta  and  mem- 
branes. The  cervical  canal  may  then  be  examined,  and  one  or 
two  fingers  passed  into  it  for  the  purpose  of  dilating  it  if  it  be 
small.  In  the  latter  case  a  piece  of  antiseptic  gauze  should  be 
pushed  through  the  cervix,  the  upper  end  being  left  in  the  uterine 
cavity  to  insure  free  drainage  into  the  vagina.  Further  diminu- 
tion in  the  size  of  the  uterus  follows.  This  may  be  hastened  by 
pouring  hot  normal  saline  solution  (iio°  F.)  into  the  uterine 
cavity ;  the  wall  is  thereby  usually  made  firm  and  pale.  The 
organ  may  then  be  placed  inside  the  abdomen. 

The  procedure  recommended  by  some  operators  of  placing  a 
rubber  tourniquet  around  the  broad  ligaments  and  lower  uterine 
segment  before  the  uterus  is  opened  is  to  be  avoided.  It  is  not 
necessary  for  the  purpose  of  checking  hemorrhage,  and  it  may 
damage  the  tissues  by  its  constricting  effect  and  interfere  with 
proper  contraction  and  retraction  of  the  uterus  afterward. 

Siitiire  of  the  Uterus. — The  author  finds  it  most  convenient  to 
approximate  the  surface  of  the  musculature  of  the  uterine  incision 
by  means  of  a  running  catgut  suture  of  medium  thickness  from 
within  outward,  in  two  or  three  layers,  a  separate  suture  being 
used  for  approximating  the  peritoneum,  whose  edges  should  be 
inverted. 

Some  operators  use  interrupted  buried  deep  and  superficial 
catgut  sutures.  Others  introduce  sutures  on  the  peritoneal  surface 
which  pass  deeply  through  the  musculature,  the  peritoneum  being 
closed  by  a  separate  row.  Various  other  forms  of  suture  material 
have  been  employed, — e.  g.,  silver  wire,  silk,  and  silkworm-gut, — 
but  these  are  not  so  satisfactory  as  catgut.  The  advice  of  Sanger, 
that  the  deep  sutures  should  not  pass  through  the  mucosa  on  the 
side  of  the  uterine  cavity,  is  not  necessary  if  operations  be  per- 
formed with  rigid  asepsis. 

Clostire  of  tJie  Abdomen. — The  pads  are  removed  from  the 
peritoneal  cavity  and  all  blood  and  liquor  amnii  sponged  out. 
The  edges  of  the  parietal  peritoneum  are  then  stitched  with  fine 


yiS  CALSAREAN  SECTION. 

catgut,  care  being  taken  to  evert  the  raw  edges.  The  rest  of  the 
incision  must  then  be  closed  by  some  well-recognized  method. 
The  navel  should  be  cut  away  and  the  edges  of  the  recti  and 
their  sheaths  brought  together  carefully.  It  is  the  author's  prac- 
tice to  flush  out  the  belly,  before  closure,  with  hot  normal  saline 
solution,  and  to  leave  a  pint  or  more  inside. 

Aftcr-trcatnicnt. — The  after-treatment  is  the  same  as  in  the 
case  of  any  abdominal  section.  The  gauze  drain  may  be  removed 
from  the  uterus  on  the  third  or  the  fourth  day.  If  the  patient 
runs  a  satisfactory  course,  the  infant  may  nurse  in  the  usual 
manner  after  the  second  or  third  day. 

Conservative  Caesarean  Section  Associated  with 
Sterilisation. — When  it  is  desirable  to  render  a  woman  sterile, 
the  operation  may  be  accompanied  by  complete  removal  of  the 
tubes,  care  being  taken  to  bury  the  stumps  in  the  uterine  wall. 
Mere  division  of  the  tubes  after  double  ligature  is  not  sufficient, 
as  pregnancy  has  been  known  to  follow  this  procedure,  owing  to 
the  succeeding  patency  of  the  uterine  end  of  the  tube.  Instead 
of  removing  the  entire  tube,  it  is  recommended  by  some  to  remove 
half  an  inch  of  the  uterine  end,  which  is  dissected  for  a  distance 
out  of  the  uterine  wall.  The  raw  surface  should  then  be  buried 
by  a  continuous  catgut  suture.  The  ovaries  need  not  be  removed 
unless  there  is  a  pathologic  indication. 

Pregnancy  Following  Csesarean  Section. — In  the  pre- 
antiseptic  days,  before  the  uterine  suture  was  employed,  preg- 
nancy occurring  after  Caesarean  section  caused  stretching  or  her- 
nial protrusion  of  the  scar  or  suture  in  a  considerable  proportion 
of  cases.  This  has  been  rarely  reported  in  modern  times,  and  is 
most  apt  to  take  place  when  the  uterus  is  much  distended. 
Caruso,  Bar,  and  Abel  have  reported  43  cases  in  which  Csesarean 
section  has  been  carried  out  two  or  rnore  times  without  a  death. 

Supravaginal  Amputation  of  the  Uterus  (Porro's 
Operation).— Indications. — Hitherto  the  most  widely  recog- 
nized indications  for  this  operation  have  been  : 

1.  The  desire  of  the  parents  not  to  run  the  risk  of  another 
pregnancy  in  cases  where  natural  labor  is  impossible.  In  refer- 
ence to  this  indication,  it  is  now  to  be  said  that  it  should  not  be 
recognized  when  the  cause  of  trouble  is  contraction  of  the  head 
or  soft  passages.  The  Porro  operation  is  longer  than  the  con- 
servative operation,  causes  more  shock  to  the  woman,  and  has  a 
higher  mortality.  Moreover,  the  woman  may  be  rendered  sterile 
by  removal  of  the  tubes,  as  above  described.  Amputation  should, 
however,  be  performed  if  there  be  extensive  tumor  formation  in 
the  uterine  body,  or  if  there  has  been  rupture  of  the  uterus  too 
extensive  to  repair  (though  in  some  cases  total  hysterectomy  of 
the  ruptured  uterus  is  most  advisable). 

2.  When  the  appendages  are  so  diseased  as  to  warrant  their 


SUPRAVAGINAL   AMPUTATION   OF   THE    UTERUS.         719 

removal.  Porro's  operation  is  advisable  when  this  compHcation 
exists  unless  the  condition  of  the  patient  contraindicates  prolonga- 
tion of  the  operation. 

3.  When  labor  has  been  prolonged  and  manipulations  have 
been  carried  out  that  have  exposed  the  woman  to  the  risk  of  in- 
fection. This  indication  is  to  be  recognized  only  when  delivery 
is  impossible  by  any  other  method.  Any  form  of  Csesarean  sec- 
tion involves  increased  risk  under  such  circumstances.  The  fetus 
should  be  removed  by  the  natural  passage  by  embryotomy  or 
symphysiotomy  if  possible ;  only  if  these  cannot  be  performed 
should  the  abdomen  be  opened  and  the  fetus  be  removed  by 
incision  of  the  uterus.  Then  it  is  best  to  remove  the  entire  uterus 
and  not  to  perform  the  Porro  operation.  Though  total  hys- 
terectomy is  a  little  longer  than  supravaginal  amputation,  the 
tissue  that  is  most  likely  to  have  been  infected  by  manipulations — 
viz.,  the  cervix — is  removed,  and  drainage  can  be  most  satisfactorily 
made  into  the  vagina. 

Operation. — As  originally  performed  by  Porro,  the  lower 
uterine  segment  was  constricted  by  a  serre  noeud  after  removal  of 
the  fetus  from  the  uterus,  which  was  not  Hfted  out  of  the  abdomen 
in  the  early  stage  of  the  operation.  The  uterus  was  then  cut 
away  and  the  stump  fastened  in  the  lower  angle  of  the  abdominal 
incision.  Miiller  modified  this  procedure  by  making  the  abdomi- 
nal opening  large  enough  to  allow  the  pregnant  uterus  to  be 
Hfted  through  it.  He  also  applied  an  elastic  ligature  around  the 
broad  ligaments  and  lower  uterine  segment  previous  to  opening  the 
uterus.  To  insure  that  the  stump  is  held  firmly  in  the  abdominal 
incision,  the  parietal  peritoneum  is  stitched  around  the  stump 
below  the  elastic  Ugature,  and  the  stump  is  transfixed  with  pins, 
which  prevent  its  recession  ;  the  rest  of  the  abdominal  incision  is 
then  closed.  The  stump  afterward  separates,  usually  between  the 
twelfth  and  fifteenth  days. 

This  extraperitoneal  method  of  treating  the  stump  is  to  be  rec- 
ommended only  when  great  haste  is  needed  and  when  the  opera- 
tion is  performed  by  one  who  is  not  an  expert  gynecologic  opera- 
tor. Under  other  circumstances  the  operation  should  be  carried 
out  so  that  the  stump  is  not  fastened  into  the  abdominal  incision. 
The  following  procedure  has  given  the  greatest  satisfaction  to  the 
author :  The  technic  is  similar  to  that  already  described  as  far  as 
the  removal  of  the  fetus  from  the  uterus.  The  amputation  is  then 
performed  as  in  the  case  of  a  fibroid  enlargement  of  the  uterine 
body.  The  round  ligaments  are  doubly  ligated  close  to  the 
uterus  and  divided.  The  appendages  may  or  may  not  be 
removed.  In  the  former  case  the  ovarian  vessels  are  then 
secured  by  a  catgut  ligature  embracing  the  infundibulopelvic 
ligament.  One  or  two  more  mass  ligatures  are  then  placed  below 
the  tube   and  ovary.     The  broad  ligament  is  then  divided  trans- 


720  CESAREAN  SECTION. 

versely  on  each  side  from  the  infundibulopelvic  Hgament  below 
the  ovary  as  far  as  the  side  of  the  uterus.  These  incisions  are 
then  joined  by  one  running  transversely  through  the  peritoneum 
above  the  junction  of  the  bladder  and  uterus,  and  by  a  similar 
one  at  the  same  level  dividing  the  peritoneum  of  the  posterior 
uterine  wall.  The  peritoneum  is  then  stripped  downward  in  front 
along  with  the  bladder,  and  also  behind  and  at  the  sides  until  the 
uterine  vessels  are  exposed.  These  are  ligated  with  catgut  and 
divided  from  the  uterus.  The  uterine  wall  is  then  divided  close 
to  the  cervix  or  through  the  upper  portion  by  a  cone-shaped  in- 
cision. The  uterine  body  is  then  removed.  The  cervical  canal 
should  be  thoroughly  burned  out  with  the  cauteiy.  The  crater- 
shaped  stump  of  the  uterus  should  then  be  closed  with  catgut 
and  carefully  covered  with  the  anterior  and  posterior  layers  of 
peritoneum.  The  edges  of  the  divided  broad  ligaments  should 
also  be  buried  with  running  catgut.  The  abdomen  is  then  closed. 
This  procedure  is  a  great  advance  beyond  the  original  Porro  pro- 
cedure, in  which  the  stump  was  stitched  into  the  abdominal  incision. 

Total  Abdominal  Hysterectomy. — The  whole  uterus 
should  be  removed  in  cases  in  which  the  genital  tract  has  been 
infected  previous  to  operation,  s}-mphysiotomy  being  impossible  ; 
when  there  is  malignant  disease  in  the  body  or  cervix,  and  in 
cases  of  bad  rupture  of  the  cervix  and  lower  uterine  segment. 

In  the  case  of  cancer  of  the  cervix  it  is  advisable  to  scrape  away 
as  much  as  possible  of  the  growth  previous  to  the  abdominal 
operation,  the  vagina  being  thoroughly  washed  out  v/ith  a  strong 
antiseptic  solution.  Some  operators,  however,  prefer  to  perform 
supravaginal  amputation  through  the  abdominal  incision,  removing 
the  cervix  afterward  by  a  \'aginal  operation,  in  order  to  lessen  the 
risk  of  infecting  the  peritoneum. 

Operation. — Special  details  of  the  technic  need  not  be  men- 
tioned, since  they  are  the  same  as  those  observed  in  the  removal 
of  the  non-pregnant  uterus  and  are  described  in  modern  works 
on  gynecology. 

Gastro-eiytrotom.y. — In  1821  Ritgen  devised  the  plan  of 
opening  the  uterus  without  entering  the  peritoneal  cavity.  During 
his  first  operation  the  hemorrhage  became  so  alarming  that  he 
abandoned  his  procedure  and  had  recourse  to  the  ordinary  Ca^sa- 
rean  section.  In  1823  Baudelocque  the  younger  had  a  similar  ex- 
perience, though  he  succeeded  on  a  second  occasion. 

In  1837  Sir  Charles  Bell  advocated  the  operation.  It  never 
became  widely  known,  however,  until  Gaillard  Thomas  reintro- 
duced it  in  1870.  Since  that  time  several  operators  have  performed 
it,  but  without  the  effect  of  popularizing  it.  Though  the  procedure 
was  a  praiseworthy  attempt  to  avoid  the  dangers  of  the  intra- 
peritoneal operation  in  the  preantiseptic  days,  it  should  have  no 
place  in  obstetric  surgery  at  the  present  time. 


GASTRO-EL  YTROTOMY.  72  I 

In  Thomas's  operation  the  wall  of  the  abdomen  is  incised  for 
several  inches  parallel  with  Poupart's  ligament,  the  peritoneum  not 
being  opened.  A  deep  dissection  is  made  external  to  the  latter 
until  the  vagina  is  reached.  The  wall  of  the  vagina  is  then 
divided  transversely  and  the  fetus  extracted  through  the  opening 
artificially  made. 

Vaginal  Csesarean  Section. — In  1895  Acconci  performed 
vaginal  incision  of  the  uterus  for  the  purpose  of  delivering  the 
fetus.  The  same  operation  was  carried  out  in  1896  by  Diihrssen, 
whose  work  has  been  chiefly  responsible  for  the  interest  taken  in 
the  procedure  by  the  profession. 

Indications. — Diihrssen  advises  the  operation  in  the  following 
conditions  : 

1.  In  new  growths  of  the  cervix,  and  rigidity  and  stenosis  of  the 
latter  ;  in  partial  sacciform  dilatation  of  the  lower  uterine  segment. 

2.  In  eclampsia,  intra-uterine  hemorrhage,  and  in  affections  of 
the  lungs,  heart,  and  kidneys  where  the  mother  is  in  danger  and 
where  rapid  delivery  is  indicated. 

3.  In  cases  in  which  the  mother  is  in  artiado  viortis. 

The  operation  has  not  yet  been  sufficiently  tested  to  warrant 
the  expression  of  a  definite  opinion  as  to  its  merits,  but  it  certainly 
deserves  a  thorough  trial. 

Technic  of  the  Operation. — A  circular  incision  is  made  through 
the  mucosa  covering  the  vaginal  portion  of  the  cervix,  close  to  the 
fornix,  and  is  extended  into  each  lateral  fornix  for  half  an  inch. 
The  mucosal  flap  is  stripped  upward  with  the  bladder,  the  cervix 
being  pulled  downward  with  a  volsella.  The  bladder  is  then  held 
up  with  a  retractor,  and  the  cervix  is  divided  in  the  middle  line 
anteriorly  and  posteriorly  if  the  case  be  at  or  near  full  term.  If  it 
be  premature,  the  posterior  lip  may  not  require  to  be  divided. 
The  cervical  incision  is  then  continued  into  the  lower  uterine  seg- 
ment anteriorly  as  far  as  necessary,  care  being  taken  not  to  enter 
the  peritoneal  cavity.  In  this  way  an  opening  in  the "  uterus  8  to 
12  cm.  in  length  maybe  obtained,  which  allows  the  passage  of  the 
fetus.  Bleeding  is  controlled  by  forceps.  If  it  is  thought  advisa- 
ble, the  uterine  vessels  may  be  ligated.  Through  the  incision  the 
fetus  is  extracted  by  version  or  forceps.  The  placenta  and  mem- 
branes are  then  removed  and  a  gauze  tampon  placed  in  the  uterus. 
The  incisions  are  then  closed  with  catgut. 

Results. — Maygrier  has  recently  collected  16  cases  reported 
by  different  operators,  with  a  maternal  mortality  of  18.75  percent. 
In  12  cancer  of  the  cervix  was  present,  and  2  of  these  died. 
The  fetus  survived  in  6  instances,  but  several  of  those  which  died 
were  premature. 

Bumm.  has  performed  13  cases,  with  i  death  due  to  eclampsia. 
He  has  tabulated  39  cases,  with  8  deaths,  of  which  3  were  due  to 
eclampsia  and  2  to  heart  disease. 

46 


722  CESAREAN  SECTION. 

Abdominal  and  Vaginal  Csesarean  Section  as  a  Means 
of  Accomplishing  Rapid  Delivery  (Accouchement  Force). 

— Abdominal  and  vaginal  Csesarean  section  are  rarely  necessary 
as  a  means  of  rapid  deliver}^  The  following  conditions  are  those 
in  which  the  operations  may  be  necessary : 

[a)  Eclampsia. — Since  1878,  when  Halbertsma  proposed  ab- 
dominal Caesarean  section  as  a  mode  of  treatment,  it  has  been 
carried  out  in  a  considerable  number  of  cases.  Kettlitz,  in  1887, 
collected  27  cases,  with  a  mortality  of  47.3  per  cent.;  Hillmann, 
in  1900,  40  cases,  with  a  mortality  of  52.5  per  cent.  These  per- 
centages are  certainly  higher  than  the  average  in  large  numbers 
of  cases  of  eclampsia  treated  by  ordinary  means.  There  seems 
indeed  no  justification  for  the  adoption  of  the  procedure  as  a 
routine  method  of  treatment.  In  rare  cases  of  eclampsia  it  may 
be  indicated — viz.,  in  those  associated  with  contractions  of  the 
birth  canal,  or  other  pathologic  changes  in  the  soft  or  hard  parts 
that  make  delivery  impossible  by  the  natural  passage. 

When,  also,  an  eclamptic  dies,  the  fetus  being  alive  /;/  ntcro^  it 
is  the  duty  of  a  physician  \\\\o  may  be  present  at  the  time  of 
death  to  advise  immediate  postmortem  Csesarean  section.  Bauer 
has  recently  reported  8  such  cases,  in  which  4  infants  were  saved. 

Vaginal  C?esarean  section  is  to  be  recommended  in  cases  of 
eclampsia  in  pregnancy  or  in  early  labor  in  which  the  cervix  is 
rigid  and  difficult  to  dilate.  As  a  means  of  delivering  a  woman 
rapidly  it  is,  in  such  a  condition,  a  safer  and  more  scientific  pro- 
cedure than  Diihrssen's  incisions  or  forcible  stretching  with  dila- 
tors, for  it  produces  a  clean  incision  in  the  mesial  plane  of  the 
cervix  and  lower  uterine  segment,  hemorrhage  from  which  may 
be  readily  controlled. 

[b)  Placenta  Prsevia. — Within  the  last  few  years  abdominal 
Caesarean  section  has  been  carried  out  in  several  cases  of  placenta 
prasvia ;  it  was  first  suggested  by  Lawson  Tait.  Zinke  has  col- 
lected 6  cases  of  the  conservative  operation  and  2  of  Porro's  opera- 
tion, in  which  5  mothers  and  6  infants  lived.  The  procedure 
has  been  widely  criticized,  and  rightly.  If  the  women  were  always 
in  the  hospital,  where  the  operation  could  be  carried  out  promptly 
by  an  expert  operator  immediately  after  the  diagnosis  was  made, 
the  results  might  be  more  satisfactory  both  to  mother  and  infant 
than  those  obtained  by  all  other  methods  of  treating  placenta 
praevia,  but  under  the  conditions  that  exist  in  ordinary  private 
practice  the  results  would  undoubtedly  be  worse.  Abdominal 
Caesarean  section  must  indeed  be  considered  as  rarely  indicated  in 
placenta  praevia  ;  practically  only  when  some  condition  exists  that 
renders  the  ordinary  methods  of  treatment  extremely  hazardous 
or  impossible.  I  have  reported  the  case  of  a  young  girl  of  four- 
teen in  whom  excessive  hemorrhage  associated  with  a  small  vagina 
and  a  contracted  pelvis  necessitated  the  operation. 


ABDOMINAL   AND    VAGINAL    CESAREAN  SECTION.      723 

Bumm  has  recently  successfully  performed  vaginal  Caesarean 
section  in  placenta  pra;via,  and  believes  that  this  operation  will 
become  important  in  certain  cases  of  this  condition — viz.,  those, 
fortunately  rare,  in  which  the  cervix  is  rigid  and  incapable  of 
easy  dilatation. 

{c)  Accidental  Hemorrhage  or  Ablatio  Placentas. — Though 
several  authorities  have  suggested  the  abdominal  Caesarean  section 
in  certain  cases  of  premature  detachment  of  the  normally  situated 
placenta,  it  has  rarely  been  employed.  It  seems  to  the  writer 
that  the  operation  should  enter  into  consideration  only  when  it  is 
impossible  to  carry  out  other  procedures  by  the  vaginal  route. 

Vaginal  Caesarean  section  is  indicated  in  cases  of  accidental 
hemorrhage  where  the  patient's  condition  is  critical  and  where  the 
cervix  cannot  be  rapidly  dilated  by  the  ordinary  methods,  pro- 
viding a  competent  operator  is  at  hand. 

{d)  Affections  of  the  heart,  lungs,  kidneys,  etc.,  where  the 
mother  is  in  danger  and  rapid  delivery  is  indicated.  In  these 
various  conditions  vaginal  section  is  indicated  where  the  cervix 
does  not  admit  of  easy  dilatation.  The  abdominal  operation 
should  not  be  employed  save  where  there  is  no  possibility  of 
satisfactorily  performing  vaginal  section. 

{e)  Cases  in  which  the  Mother  is  In  Articulo  Mortis. — If  a 
physician  be  present  at  the  death  of  a  pregnant  woman  carrying 
a  viable  fetus,  it  should  be  his  duty  to  advise  immediate  Caesarean 
section,  in  the  hope  of  saving  the  latter.  Bauer  has  collected  re- 
ports of  1 5  such  operations.  In  3  only  was  the  fetus  dead ;  in  2 
it  was  alive,  but  soon  died;  while  in  10  it  lived.  In  8  of  these 
cases  the  mother's  death  was  due  to  eclampsia,  and  in  4  the  fetus 
was  saved.  Only  3  of  the  10  breathed  on  being  extracted.  All 
were  more  or  less  asphyxiated,  yet  were  resuscitated.  In  i  case 
Bauer  observed  that  after  removal  of  the  fetus,  placenta,  and 
membranes,  uterine  retraction  immediately  took  place. 

The  abdominal  operation  is  by  far  the  simplest  and  quickest  in 
such  cases,  for  it  can  be  performed  merely  with  a  knife  and  with- 
out assistance.  The  vaginal  operation  has  also  been  recom- 
mended, but  it  would  probably  occupy  a  longer  period  than  the 
other  and  assistance  would  be  needed. 


724 


S  YMPH  YSIO  TOM  Y. 


CHAPTER   V. 

SYMPHYSIOTOMY  (SYMPHYSEOTOMY,   SYMPHY- 

SOTOMYj. 

Symphysiotomy  is  an  operation  that  consists  in  dividing  the 
symphysis  pubis,  in  order  that  the  ossa  innominata  may  be  sepa- 
rated ;  the  bony  canal  is  thereby  enlarged  and  the  delivery  of  the 
fetus  facilitated.  The  operation  was  first  performed  on  a  woman, 
immediately  after  her  death,  by  de  la  Courvee,  of  Warsaw  (the 
date  is  not  exactly  known — somewhere  between  1585  and  1655). 
In  1766  Plenck  practised  it  also  on  a  dead  woman.  In  1768 
Sigault,  a  Paris  medical  student,  proposed  that  the  operation  be 
employed  on  a  living  w^oman.  In  1774  Ferrara,  an  Italian,  who  had 
been  in  Paris  and  had  heard  of  Sigault's  suggestion,  first  carried 
out  the  operation  on  a  living  woman,  in  Naples,  the  woman  dying. 
In    1777  Sigault  performed   the  first   successful  operation,  both 


Fig.  318. — Section  across  symphysis  pubis,  showing  pubic  disk  (Lusk). 

the  mother  and  child  surviving,  though  the  former  was  left  with  a 
vesicovaginal  fistula,  a  prolapse  of  the  uterus,  and  walked  with  a 
waddling  gait.  Sigault's  operation  was  bitterly  condemned  by 
many  leading  surgeons,  and  during  the  next  one  hundred  years 
was  little  practised.  Neugebauer  collected  1 36  cases  reported  be- 
tw^een  1777  and  1866,  of  which  56  were  Italian.    Between  1820  and 

1890  the  operation  was  chiefly  performed  in  Naples.  Since  1866 
it  has  been  mainly  advocated  by  Morisani  and  his  pupils.     In 

1 89 1  Pinard,  of  Paris,  was  induced  to  tr>^  symphysiotomy,  and 
during  the  next  few  years  performed  a  considerable  number  of 
operations.     Jewett  reported  the  first  case  in  America  in  1892. 

Scope  of  the  Operation. — Symphysiotomy  was  introduced 
into  practice  as  a  substitute  for  Csesarean  section  on  account  of 
the  high  mortality  of  the  latter  procedure.  The  work  of  Morisani 
and  Pinard  for  a  time  seemed  likely  to  make  the  operation  widely 


SCOPE    OF   THE    OPERATION. 


725 


popular,  but  recently  it  has  gradually  taken  a  less  prominent  posi- 
tion, while  Gaesarean  section  has  grown  more  into  favor.  This  is 
due  partly  to  the  disadvantages  associated  with  symphysiotomy, 
but  largely  to  the  marked  improvement  in  the  results  of  Ctesarean 
section.  Though  the  maternal  mortality  in  both  operations  has 
diminished,  it  is  doubtful  if  symphysiotomy  can  claim  at  the 
present  time  a  lower  death-rate,  while  it  undoubtedly  has  a  record 
of  after-troubles  unknown  to  the  other  operation. 

Symphysiotomy  is  condemned  by  many  as  an  unscientific  pro- 
cedure, not  to  be  practised  under  any  circumstances.  While  this 
position  is  too  extreme,  it  must  be  admitted  that  the  operation 
has  a  very  limited  range  of  usefulness.  The  operation  does  not  de- 
liver the  woman :  it  merely 
affords  room  for  the  pas- 
sage of  the  fetus  at  the 
sacrifice  of  the  normal 
architecture  of  the  bony 
pelvis.  To  it  must  be 
added,  usually,  the  risks 
of  artificial  delivery  by 
version  or  forceps.  More- 
over, it  is  easy  to  mis- 
calculate the  size  of  the 
fetal  head  as  well  as  the 
amount  of  gain  following 
separation  of  the  bones. 
Immediate  and  remote 
risks,  maternal  and  fetal, 
must,  therefore,  be  ex- 
pected in  a  certain  per- 
centage of  cases  unless  the 
operation  be  restricted 
within  narrow  limits. 
When  it  is  carried  out  in 
too  contracted  a  pelvis 
the  dangers  are  very  great. 
Jewett  holds  that  it  is  suited 

to  those  cases  in  which  only  a  slight  additional  space  is  required 
for  delivery,  and  that  it  may  prove  valuable  when  the  axis-traction 
forceps  unexpectedly  proves  inadequate.  He  thinks  that  it  should 
not  be  used  in  flat  pelves  with  a  conjugate  less  than  7.5  cm.  (3  in.), 
or  in  justominor  pelves  with  one  less  than  9  cm.,  if  the  fetal  head 
be  of  normal  size.  It  may  sometimes  be  advisable  in  certain  im- 
pacted face  or  occipitoposterior  cases.  When  the  woman  has  been 
greatly  exhausted  or  has  been  subjected  to  the  risk  of  infection, 
symphysiotomy  should  replace  Crcsarean  section  when  the  passage 
is  large  enough. 


Fig.  319. — Separation  of  sacro-iliac  joint  on  open- 
ing pubic  symphysis  (Faraboeuf ). 


726  SYMPHYSIOTOMY. 

Symphysiotomy  performed  for  the  purpose  of  affording  in- 
creased space  at  the  outlet  is  safer  than  when  it  is  used  for 
expediting  delivery  of  the  head  above  the  brim  ;  it  may,  there- 
fore, be  adopted  in  funnel-shaped  or  kyphotic  pelves  when  the 
outlet  is  not  quite  large  enough  to  allow  safe  delivery  with  forceps. 
In  all  cases  in  which  symphysiotomy  is  performed  the  fetus  must 
be  alive.  Caesarean  section  has  a  great  advantage  over  symphy- 
siotomy in  that  the  risks  of  the  operation  are  independent  of  the 
degree  of  pelvic  contraction,  and  the  relationship  between  the 
latter  and  the  fetal  head.  It  offers  greater  chances  of  safety  to 
the  fetus,  other  conditions  being  the  same.  Symphysiotomy 
should  not  be  carried  out  where  there  is  inflammation  or  ankylosis 
in  the  sacro-iliac  joints. 

Bffects  of  the  Operation  on  the  Pelvic  Measure- 
ments.— When  the  pubic  symphysis  and  subpubic  ligament  are 
divided,  the  ossa  innominata  may  be  moved  to  a  certain  extent  at 
their  junction  with  the  sacrum.  This  movement  is  greater  in 
pregnancy  than  in  the  non-pregnant  state,  owing  to  the  softening 
of  the  ligaments  of  the  joints  in  the  former  condition.  As  the 
pubic  bones  are  separated  they  move  somewhat  downward,  owing 
to  the  peculiar  shape  of  the  sacro-iliac  joints.  As  a  result  there 
is  an  increase  in  the  available  space  for  the  passage  of  the  fetus. 
The  true  conjugate  is  lengthened,  the  gain  vaiying  according  to 
the  degree  of  descent  of  the  pubes,  the  separation  of  the  bones, 
and  the  size  of  the  pelvis.  Budin  and  Demelin  give  the  follow- 
ing table : 

Extent  of  separation  C     h    at  Increase  in 

of  pubic  bones.  v-onj   g    e.  conjugate. 

7  cm.  (2|  in.).  6  cm.  (2-J  in.).  1.3  cm.  (^'^  in.). 

7    "  7    "  1.2    " 

7    "  8    "  I.I    " 

7    "  9    "  I       " 

A  separation  of  7  cm.  is  the  extreme  limit  of  safety  and  should 
rarely  be  reached.  Consequently,  when  a  lesser  degree  of  separa- 
tion is  obtained,  the  gain  in  the  conjugate  is  less  than  is  figured 
in  this  table.  To  be  well  on  the  side  of  safety,  the  extent  of 
pubic  separation  should  probably  never  be  greater  than  6  cm. 
Sandstein  holds  that  symphysiotomy  should  never  be  performed 
with  a  conjugate  of  less  than  2.78  in.  (7.3  cm.).  Morisani  also  states 
that  there  is  not  much  scope  for  the  operation  when  the  conjugata 
vera  is  below  7  cm.  In  general  it  may  be  said  that  rarely  can  an 
increase  in  the  conjugate  greater  than  -f  in.  (i  cm.)  be  obtained. 
There  is  also  an  increase  in  the  oblique  diameter  one  and  a  half 
times  that  of  the  conjugate,  and  in  the  transverse  about  twice  as 
much.  Moreover,  new  space  is  gained  between  the  ends  of  the 
separated  bones,  into  which  the  presenting  part  of  the  fetus  may 
bulge  as  it  descends,  the  increase  varying  directly  with  the  degree 


EFFECTS   OF   OPERATION  ON  PELVIC  MEASUREMENTS.   727 

of  separation.  To  obtain  the  most  satisfactory  result,  the  ossa  in- 
nominata  must  be  moved  outward  an  equal  distance  from  the  middle 
line.  In  estimating  the  gain  to  be  derived  from  symphysiotomy, 
one  must  examine  not  only  the  pelvic  brim,  but  also  the  condi- 
tion of  the  anterior  surface  of  the  sacrum,  for  if  the  latter  be  flat- 
tened or  bulging,  the  dystocia  may  not  be  limited  entirely  to  the 
inlet. 

Sandstein  describes  the  movements  occurring  during  the  sepa- 
ration of  the  bones  after  symphysiotomy  as  follows : 

1.  Movement  of  the  pubes  outward  by  rotation  of  the  in- 
nominate bones  on  vertical  axes  passing  through  the  respective 
sacro-iliac  joints. 

2.  Rotation  of  the  innominate   bones   on  a   transverse   hori- 


FlG.  320. — Effect  of  descent  of  pubic  bones  on  gain  in  length  of  sacropubic  diameter. 
By  mere  separation  of  bones  the  gain  in  conjugata  vera  would  be  S,S'\  with  added  effect 
of  descent  it  is  S" ,  S'"  (Wehle). 

zontal  axis  passing  through  the  sacrum,  carrying  the  pubes  down- 
ward. 

3.  Rotation  of  each  innominate  bone  on  its  own  long  axis  (an 
axis  lying  in  a  direction  from  the  posterosuperior  iliac  spine  to  the 
iliopectineal  eminence),  so  as  to  cause  the  ilium  to  become  more 
erect  or  vertical.  As  the  pubes  pass  downward  and  outward  and 
the  ischial  tuberosities  are  carried  farther  apart,  the  iliac  crests 
approximate  one  another. 

He  considers  that  the  true  significance  of  the  operation  in  in- 
creasing the  brim  conjugate  lies  chiefly  in  the  fact  that  it  thereby 
permits  increased  descent  of  the  pubic  bones  from  their  original 


728 


S  YMPHYSIO  TOMY. 


level,  and  holds  that  symphysiotomy  is  really  a  means  of  obtain- 
ing the  results  afforded  by  Walcher's  position,  only  in  a  greater 
degree. 

With  6  cm.  of  pubic  separation,  a  mean  depression  of  the 
pubes  to  the  distance  of  8.4  mm.  can  be  obtained.  Walcher's 
position  alone  gives  a  maximum  descent  of  5  mm.  The  outward 
movement  of  the  pubic  bones  is  usually  a  minor  factor  in  pro- 
ducing increase  of  the  conjugate. 

Operation. — The  operation  should  be  carried  out  when  the 
cervix  is  completely  dilated.  If  dilatation  be  incomplete,  it  should 
be  increased  by  manual  stretching  or  by  rubber  bags. 


Fig.  321. — Diagram  of  pelvic  brim,  showing  gain  in  space  on  opening  pelvic  joint :  P,S, 
Conjugate  jomt  closed;  P,S' ,  conjugate  joint  open  6  cm.  (Wehle). 


The   patient  is  placed   on    a   table,  in  the  lithotomy  position, 
shaved,  and  prepared  as  for  a  surgical  operation. 

Various  methods  are  employed  for  dividing  the  symphysis : 
I.  Open  Method. — After  a  metal  catheter  is  inserted  into  the 
urethra,  a  mesial  incision  through  the  skin  and  subcutaneous  fat 
is  carried  from  a  point  3  cm.  {i\  in.)  above  the  pubes  to  as  low  as 
the  clitoris.  The  latter  is  then  drawn  down  while  its  suspensory 
ligament  is  separated  from  the  subpubic  ligament,  care  being  taken 
not  to  injure  its  dorsal  vessel.  The  upper  edge  of  the  symphysis 
is  then  exposed,  the  insertions  of  the  recti  muscles  divided,  and  a 


EFFECTS    OF   OPERATION  ON  PELVIC  MEASUREMENTS.  729 

finger  introduced  between  them,  in  order  to  separate  the  tissues 
from  the  posterior  surface  of  the  symphysis.  A  director  is  then 
placed  behind  the  latter,  being  introduced  above  or  below ;  it 
protects  the  soft  tissues  while  the  symphysis  is  divided.  The 
division  is  made  with  a  short  knife  or  scissors,  from  without  in- 
ward or  from  within  outward.  Care  should  be  taken  not  to  strip 
the  periosteum  from  the  bone. 

2.  Subcutaneous  Method. — Many  Italians  favor  the  plan  of 
making  a  mesial  incision  an  inch  in  length  above  the  symphysis, 
in  order  that  a  forefinger  may  be  introduced  between  the  inser- 
tions of  the  recti,  for  the  purpose  of  separating  the  tissues  from 
the  posterior  surface  of  the  symphysis  and  protecting  them  while 
a  curved  probe-pointed  bistoury  or  Galbiati's  knife  is  passed  behind 
the  symphysis  to  divide  the  joint  from  below  upward.  If  the 
subpubic  ligament  is  not  cut,  it  is  necessary  to  introduce  another 


Fig.  322. — Diagram  of  pelvic  brim,  showing  gain  of  space  on  separation  of  sym- 
physis. Pubic  joint  closed,  pelvic  cavity  admits  a  sphere  80  mm.  in  diameter;  joint 
opened  6  cm.,  the  cavity  admits  a  sphere  98  mm.  in  diameter  (after  Faraboeuf  ). 

smaller  knife  for  the  purpose.  Some  hold  that  it  is  best  not  to 
cut  the  subpubic  ligament  in  most  cases,  in  order  to  prevent  vagi- 
nal rupture  and  secondary  slipping  of  the  bladder  into  the  joint. 
Harris  recommends  dissecting  the  ligament  from  the  pubes  for 
a  short  distance  on  each  side  of  the  middle  line.  If  there  be 
much  bleeding,  the  wound  may  be  packed  for  a  few  minutes  with 
gauze. 

Ayers'  Method. — After  the  clitoris  is  raised  from  the  symphysis 
an  inci-sion  is  made  below  it  with  a  narrow  sharp  knife  and  carried 
vertically  upward  subcutaneously  nearly  to  the  upper  end  of  the 
symphysis.  Through  this  incision  a  straight  blunt-pointed  bistoury 
is  introduced,  in  order  to  divide  the  joint  from  above  downward 
and  before  backward.     A  metal   catheter  is   kept  in  the  urethra 


7  3  O  S  YMPH )  'SIO  TOM  V. 

while  this  is  being  done,  and  a  finger  in  the  vagina  guides  the 
blunt  end  of  the  bistoury. 

After  the  division  an  assistant  should  stand  on  each  side  of  the 
patient's  hips,  supporting  the  thighs  and  placing  a  hand  against 
the  trochanter.  During  descent  of  the  head  pressure  may  be 
made  over  the  wound  to  lessen  the  risk  of  rupture  of  the  anterior 
vaginal  wall. 

Spontaneous  delivery  may  take  place  after  the  division  of  the 
symphysis,  in  which  case  close  attention  must  be  given  to  the 
pelvic  bones,  in  order  that  separation  may  be  symmetric  and  not 
excessive.  Zweifel  strongly  urges  that  labor  should  be  spon- 
taneous, claiming  that  the  results  are  much  more  satisfactory  than 
when  artificial  delivery  is  employed.  Most  authorities,  however, 
advise  artificial  delivery.     Version  is  strongly  recommended  by 


Fig.  323. — Diagram  of  pelvic  brim,  showing  gain  of  space  on  separation  of  sym- 
physis. Pubic  joint  closed,  the  pelvic  cavity  admits  a  sphere  60  mm.  in  diameter; 
joint  opened  6  cm.,  the  excavation  admits  a  sphere  84  mm.  in  diameter  (after  Faraboeuf ). 

some  and  condemned  by  others.  Many  advocate  exclusively  the 
use  of  axis-traction  forceps  in  head  presentations.  When  extrac- 
tion has  begun,  the  pubic  bones  tend  to  move  apart.  It  is  the 
duty  of  the  assistants  to  steady  the  thighs  and  press  inward  against 
the  trochanters,  in  order  to  prevent  sudden  or  excessive  separa- 
tion. It  is  best  that  the  limbs  should  be  held  in  Walcher's  posi- 
tion. The  operator  must  see  that  the  ends  of  the  pubic  bones 
move  outward  equally  distant  from  the  middle  line ;  that  one 
which  moves  out  farthest  takes  a  lower  level  than  the  other. 
Should  one  bone  move  but  slightly  and  the  other  excessively, 
there  is  a  great  risk  that  the  ligaments  of  the  sacro-iliac  joint  on 
the  side  of  the  latter  may  be  badly  torn.  When  there  is  an  asym- 
metric movement  of  the  bones,  the  Walcher  position  must  not 
be  adopted.     The  soft  structures  anterior  to  the  birth  canal  must 


COM  PL  ICA  riONS.  7  3 1 

be  carefully  protected,  the  external  incision  being  packed  with 
gauze,  which  may  be  held  in  position  with  sterile  adhesive  plaster. 

Some  authors,  notably  Faraboeuf,  recommend  forcible  separa- 
tion of  the  bones  after  division  of  the  symphysis.  This  is  apt  to 
injure  the  ligaments  more  than  will  the  gradual  separation  just 
described. 

It  has  also  been  recommended  that  instead  of  employing  assist- 
ants to  hold  the  hips,  it  is  advisable  to  encircle  the  hips  with  a 
flannel  binder,  which  gives  some  support  but  does  not  prevent 
gradual  separation.  After  delivery  is  completed  the  separated 
bones  are  brought  together,  care  being  taken  not  to  pinch  the 
bladder  between  them.  Dawbarn  suggests  filling  the  bladder  with 
fluid  before  bringing  the  bones  together,  in  order  to  raise  it  above 
the  brim,  so  that  it  may  not  be  pinched  between  the  pubic  bones. 

If  the  bladder  has  been  torn,  the  rent  should  be  closed  with 
catgut ;  in  such  a  case  continuous  drainage  of  the  bladder  by  a 
catheter  placed  in  the  urethra  is  advisable  for  a  few  days.  The 
fibrous  tissues  in  front  of  the  joint  may  be  stitched  with  chromic 
catgut  and  the  external  incision  closed.  A  dressing  is  placed  over 
the  pubes  and  held  in  position  with  adhesive  plaster.  The  hips 
may  then  be  encircled  with  a  firm  canvas  binder  or  with  ad- 
hesive-plaster strips.  The  patient  may  then  be  placed  on  a  hard 
bed,  her  legs  being  kept  straight  and  bound  together  at  the 
knees,  a  long  sand  bag  being  placed  against  the  pelvis  and  thighs. 
Ayers'  hammock  bed  is  an  excellent  arrangement  for  keeping 
the  bones  together  and  facilitating  the  nursing.  The  after-care  is 
very  troublesome.  The  greatest  care  must  be  taken  to  keep  the 
external  genitals  clean  and  to  avoid  disturbance  of  the  bones  when 
the  bedpan  is  used.  The  genitals  should  be  washed  with  an  anti- 
septic lotion  two  or  three  times  a  day. 

Zweifel  recommends  draining  the  prevesical  space  into  the 
vagina  after  symphysiotomy  in  all  cases,  in  order  to  diminish  the 
risks  if  infection  occurs.  For  this  purpose  he  employs  a  glass 
tube  covered  with  rubber.  In  case  the  vagina  is  infected  he 
carries  the  tube  through  one  of  the  labia  majora,  below  the 
corpus  cavernosum.  To  place  the  latter  in  position,  the  hips  of 
the  patient  should  be  raised  and  steadied  by  an  assistant.  If 
vaginal  or  uterine  douches  are  necessary,  they  may  be  given  with 
least  disturbance  to  the  patient  by  flexing  the  thighs  toward  the 
abdomen  without  separating  them.  The  woman  should  be  kept 
on  her  back  for  three  weeks,  and  for  the  same  period  longer  in 
bed,  the  binder  being  kept  in  position.  When  she  sits  up,  the 
latter  should  not  be  removed. 

Complications. — Excessive  subcutaneous  fat  increases  the 
difficulty  of  the  operation.  When  the  uterus  bulges  markedly 
over  the  .symphysis,  it  should  be  held  well  up  by  assistants  while 
the  incision  is  made.     Sometimes  the  division  is  difficult  owing  to 


732  SYMPHYSIOTOMY. 

ossification  in  the  joint ;  in  such  a  condition  a  chain-saw  or  chisel 
may  be  needed.  Several  authors  state  that  ossification  is  never 
found,  cases  described  as  such  being  those  in  which  the  joint  has 
been  missed  and  the  bone  divided.  Sandstein  points  out  that  the 
upper  end  of  the  symphysis  is  not  always  in  the  middle  line.  In 
50  per  cent,  of  cases  examined  it  was  mesial ;  in  33^  per  cent,  to 
the  left;  in  i6|  per  cent,  to  the  right.  In  60  cases  examined  by 
Wehle  it  was  mesial  in  13^  per  cent. ;  in  66f  per  cent,  to  the  left ; 
in  20  per  cent,  to  the  right.  Hemorrhage  may  sometimes  be  ex- 
cessive and  alarming,  owing  to  the  division  of  large  veins,  es- 
pecially during  division  or  separation  of  the  bones.  This  may  be 
aggravated  after  deliver}-  of  the  fetus.  Rupture  of  the  anterior 
vaginal  wall  or  vulva  may  be  produced,  especiall}'  in  primiparae. 
The  urethra  or  bladder  may  be  torn,  either  as  the  result  of  separa- 
tion of  the  bones  or  of  extraction  of  the  fetus.  In  performing 
symphysiotomy  on  a  woman  who  has  already  passed  through  the 
operation  the  bladder  and  urethra  are  apt  to  be  torn  in  separating 
them  from  the  pubes,  to  which  they  have  become  adherent  by 
strong  fibrous  union. 

Sandstein  points  out  that  the  anterior  and  superior  sacro-iliac 
ligaments  are  apt  to  tear,  beginning  in  the  latter,  because  the  upper 
margin  of  the  lateral  mass  of  the- sacrum  is  made  to  project  above 
the  corresponding  upper  border  of  the  articular  surface  of  the 
ilium.  In  his  experiments  rupture  began  in  44  per  cent,  of  cases 
with  less  than  6  cm.  of  pubic  separation,  and  in  56  per  cent,  with 
6  cm.  or  more  ;  in  2  it  began  only  at  8  cm.,  and  in  i  not  even 
at  8  cm. 

The  mons  veneris  was  often  affected  ;  after  7  cm.  it  always  tore. 
In  30  cases  of  lacerations  directly  due  to  the  symphysiotomy, 
collected  by  Sandstein,  the  trouble  was  due  to  extension  of  the 
operation  wound  in  5  ;  in  7  to  tear  of  the  vestibule  ;  in  i  to  tear 
of  the  labium  minor  ;  in  9  the  anterior  vaginal  wall  was  ruptured  ; 
in  3  the  urethra;  in  2  the  vestibule,  clitoris,  and  urethra  ;  in  i  the 
urethra  and  vagina ;  in  i  the  urethra,  bladder,  and  vagina ;  in  i 
the  urethra,  vagina,  cervix,  and  perineum.  Lacerations  are  also 
caused  by  mismanaged  labor. 

After  delivery  there  may  be  trouble  from  various  sources. 
The  smaller  the  pelvis,  the  slower  the  convalescence.  Hemorrhage 
sometimes  occurs.  Infection  is  apt  to  follow  ;  Bar  reports  fever  25 
times  in  62  cases — i.  c,  31  percent.  Various  urinary  disturbances 
may  be  present.  The  patient  may  be  unable  to  pass  water ;  or  may 
be  unable  to  hold  it,  owing  to  paralysis  or  division  of  the  urethra. 
Infection  of  the  urethra  and  bladder  is  not  infrequent.  Prolapse 
of  the  bladder  and  uterus  has  been  reported  in  a  number  of  cases. 
There  may  be  weakness  in  the  pelvis,  a  sense  of  insecurity,  and 
impairment  of  gait  for  a  long  period  after  operation.  Sometimes 
a  fibrous  band  may  form  between  the  pubic  bones,  which  stretches 


EMBRYOTOMY. 


7  !ib 


and  allows  of  movement.  In  some  cases  the  sacro-iliac  joints  are 
tender  for  a  long  period  and  may  become  the  seat  of  an  arthritis. 
Suppuration  or  caries  in  these  joints  is  rare  ;  in  300  cases  collected 
by  Sandstein  neither  of  these  complications  occurred. 

Prognosis. — Before  the  antiseptic  period  the  mortality  after 
symphysiotomy  was  high.  Harris  collected  105  operations  per- 
formed between  1777  and  1866,  with  a  maternal  mortality  of  31 
per  cent,  and  a  fetal  mortality  of  15  per  cent.  In  1881  Morisani 
reported  50  cases,  with  20  per  cent,  mortality  both  for  mothers 
and  infants.  In  1885  he  published  18  additional  cases,  with  a 
maternal  mortality  of  44.4  per  cent,  and  a  fetal  mortality  of  27.7 
per  cent.  Spinelli  collected  24  cases  performed  between  1888  and 
1 89 1,  all  the  mothers  and  23  infants  surviving.  Neugebauer  has 
collected  278  cases,  with  a  maternal  mortality  of  ii.i  per  cent.; 
Rubinrot,  136  cases,  with  a  mortality  of  11.03  P^^  cent.  Pinard 
has  reported  100  cases,  with  12  deaths.  Rubinrot  places  the  fetal 
mortality  at  13.97  per  cent.,  Pinard,  at  13  percent.  Zweifel  reports 
31  cases,  with  a  fetal  mortality  of  6.54  per  cent. 


CHAPTER   VI. 

EMBRYOTOMY. 

This  term  is  applied  to  all  procedures  that  have  for  their  end 
the  diminution  of  the  bulk  of  the  fetus,  hving  or  dead,  so  that  it 
may  be  deHvered  through  the  genital  canal.  It  includes  the  re- 
duction of  the  head  or  body,  or  both  head  and  body. 

Within  recent  years  the  necessity  for  this  procedure  on  the 
living  child  has  been  reduced,  owing  to  the  use  of  axis-traction 
forceps,  to  the  increased  safety  of  Caesarean  section,  induction  of 
premature  labor,  and  symphysiotomy.  Many  authorities  declare 
that  the  living  fetus  should  never  be  destroyed,  because  of  the 
great  diminution  in  the  maternal  mortality  attendant  upon  alter- 
native measures  adopted  to  save  the  fetus  ;  others  hold  the  same 
view  on  religious  grounds.  In  the  Anglo-Saxon  countries  the 
life  of  the  mother  has  always  been  considered  of  the  first  im- 
portance, and  there  has  been  little  prejudice  against  embryotomy 
on  the  living  fetus.  Within  recent  years  there  has  been  a  tendency 
to  the  more  frequent  adoption  of  measures  calculated  to  save  the 
fetus  as  well  as  the  mother.  The  choice  of  procedure  must  de- 
pend to  a  large  extent  upon  the  circumstances  in  which  the 
patient  is  placed.  In  skilled  hands  a  Caesarean  section  performed 
at  a  chosen  time  is  a  comparatively  safe  operation  ;  in  unskilled 
hands   it  is  a  very  dangerous   operation.      Symphysiotomy  also 


734 


EMBRYOTOMY. 


should  never  be  attempted  save  where  the  operator  is  an  expert 
and  the  facihties  are  satisfactory.  Embryotomy,  though  not  by  any 
means  free  from  dangers,  is  a  safer  procedure  in  unskilled  hands 
than  a  Cesarean  section  or  symphysiotomy.  At  the  present  day 
emergency  work  in  conditions  calling  for  any  of  these  operations 
should  rarely  be  necessary.  If  medical  practitioners  examined 
their  patients  thoroughly  during  pregnancy  they  could  detect 
most  of  the  conditions  that  need  these  serious  operations — /.  e., 
deformed  pelves,  tumors,  contracted  soft  passage,  etc.,  and  could 
arrange  to  send  the  women  to  large  cities  for  expert  care  if  they 


Fig.  324. — Trephine  of  Rraun  (curved  and  straight). 

felt  unable  to  attend  to  them.  There  are  few  districts  in  most 
civilized  countries  where  such  an  arrangement  could  not  be  made. 

Craniotomy. — Under  this  heading  are  described  the  methods 
of  reducing  the  head  in  order  to  facilitate  delivery. 

Indications. —  i.  Disproportion  between  the  size  of  the  fetal 
head  and  the  hard  or  soft  passages,  due  to  contractions  of  the 
latter.  If  the  fetus  be  dead,  the  indication  to  perform  craniotomy 
is  absolute,  unless  the  contraction  in  the  canal  be  too  great,  when 
delivery  by  the  abdominal  route  is  necessary.  The  operation 
may  be  very  difficult  with  a  conjugate  of  2\  in.,  and  should  never 
be  attempted  when  it  measures  less  than  2  in.     When  the  fetus  is 


Fig.  325. — Perforator  of  Smelhe. 


alive,  the  procedure  must  be  considered  as  an  alternative  to 
Caesarean  section,  or  symphysiotomy  with  forceps  extraction  or 
turning,  the  choice  depending  upon  the  situation,  circumstances, 
and  expertness  of  the  attendants. 

2,  Tumors  of  the  hard  or  soft  parts — /.  e.,  ovarian  tumor,  cer- 
tain fibroids,  carcinoma  of  the  cervix,  bony  growths,  etc.  All 
these  conditions  are  also  indications  for  Caesarean  section,  and 
craniotomy  should  never  be  undertaken,  if  the  fetus  be  alive, 
except  when  the  other  operation  cannot  be  performed.  If  the 
fetus  be  dead,  craniotomy  is  indicated,  unless  it  is  regarded  as 
more  dangerous  than  the  abdominal  operation. 


CRANIOTOMY. 


735 


3.  Prolapsus  funis,  when  the  fetus  is  dead  and  a  disproportion 
exists  between  the  head  and  the  passage. 

4.  Hydrocephalus  and  certain  fetal  deformities — e.  g.,  mon- 
strosity. 

5.  Malpositions  and  malpresentations — e.  g.,  impacted  brow 
and  face,  and  malrotated  occipitoposterior,  when  the  fetus  is  dead. 
When  the  fetus  is  alive  and  circumstances  are  favorable,  other 
procedures  that  are  capable  of  saving  the  fetus  as  well  as  the 
mother  must  be  considered  as  alternatives — 1\  g.,  symphysiotomy. 


Fig.  326. — Craniotomy  forceps  of  Meigs. 

Caesarean  section  may  sometimes  be  employed,  but  only  when  the 
fetal  head  has  not  descended  into  the  pelvis. 

6.  When  rapid  delivery  is  necessary  for  the  sake  of  the  mother. 
In  any  case  where  rapid  delivery  is  advisable  on  account  of  the 
mother's  condition,  delivery  after  craniotomy,  if  the  fetus  be  dead, 
is  less  risky  than  forceps  application,  and  should  be  employed 
when  the  head  is  at  the  brim,  especially  if  the  cervix  be  not  quite 
fully  dilated.  If  the  fetus  be  ahve,  turning  or  axis-traction  forceps 
must  be  regarded  as  alternative  plans  if  the  conditions  be  favorable. 

7.  When   the   fetus   might  be   extracted  with   forceps  but  is 


Fig.  327. — Cranioclast  of  Braun. 


dead,  craniotomy  should  be  performed  unless  there  is  a  strong 
objection  on  the  part  of  the  parents  to  disfigurement,  or  unless 
the  forceps  cannot  be  safely  used. 

Prognosis. — Destruction  and  delivery  of  the  fetus  are  more 
risky  according  to  the  difficulties  of  the  procedure.  The  maternal 
tissues  may  be  bruised  or  cut,  causing  loss  of  blood  and  favoring 
infection.  The  uterus,  bladder,  or  rectum  may  be  perforated.  If 
the  patient  has  been  long  in  labor,  or  if  she  has  been  injured  by 
attempts  at  delivery  by  forceps  or  version,  the  dangers  of  em- 


736 


EMBRYOTOMY. 


bryotomy  are  increased,  as  are  those  of  any  operative  procedure. 
Delay  in  performing  the  operation  after  it  has  been  found  neces- 
sary is  a  serious  mistake. 

Operation. — Craniotomy  may  be  considered  in  three  stages  : 
{a)  Perforation  ;   [p)  head  comminution,  and  {c)  extraction. 

{a)  Perforation. — Various  types  of  perforators  have  been  de- 
vised— /.  €.,  knives,  boring-screws,  scissors,  and  trephines.  Of 
these  only  the  second  and  third  varieties  need  be  noted.  Sir 
J.  Y.  Simpson's  perforator  is  a  modification  of  the  scissors  type 
and  is  one  of  the  best.  The  halves  do  not  cross  and  the  blades 
cannot  be  opened  until  the  handles  are  compressed.  Smellie's 
instrument  is  of  the  scissors  type.  Lucas-Championniere's  per- 
forator has  a  boring-screw  like  a  gimlet.  Of  this  type  is  the 
basilyst  of  A.  R.  Simpson,  which  was  introduced  for  crushing  the 
base,  but  serves  admirably  for  opening  the  vault  of  the  skull.  In 
emergency  cases,  where  no  proper  perforator  is  at  hand,  a  large 
pair  of  scissors  may  be  used. 

Preliminaries  to  Perforatio7i. — The    patient    is    placed  in   the 


Fig.  328. — Auvard's  combined  perforator,  cranioclast,  and  cephalotribe. 


lithotomy  position,  anesthetized,  the  bladder  and  rectum  being 
emptied.  Strict  asepsis  is  observed.  The  relation  of  the  head  to 
the  brim  is  carefully  studied.  An  assistant  should  be  at  hand  to 
hold  the  head  in  position  by  pressure  through  the  abdominal  wall 
at  the  moment  determined  by  the  operator ;  he  must  be  careful 
not  to  allow  the  head  to  slip  away.  If  no  help  be  available,  the 
scalp  may  be  held  by  a  strong  volsella  while  the  skull  is  per- 
forated. When  the  head  is  impacted  in  the  pelvis,  the  aid  of  an 
assistant  may  not  be  necessary.  The  cei-vix  should  be  fully  or 
nearly  dilated  and  the  membranes  ruptured.  If  the  operation  is 
indicated  when  the  cervix  is  only  partially  opened,  dilatation 
should  be  completed  by  means  of  rubber  bags  or  by  digital 
manipulations.  To  introduce  the  perforator,  the  fingers  of  the 
left  hand  should  be  passed  up  the  vagina,  holding  the  end  of  the 
instrument  to  guide  it  and  to  protect  the  vaginal  wall  from  injury. 


CRANIOTOMY. 


717 


It  should  then  be  directed  at  right  angles  to  the  surface  of  the 
skull,  and  should  be  made  to  enter  by  semi-rotary  movements  if 
an  instrument  with  flat  blades  be  used  ;  by  a  boring  movement 
if  the  screw  instrument  be  employed.  During  this  procedure  the 
head  must  be  held  firmly,  and  care  must  be  taken  to  prevent  the 
instrument  from  slipping  and  injuring  the  maternal  tissues. 

If  possible,  a  flat  bone  should  be  pierced,  and  the  opening 
should  be  made  nearer  the  symphysis  than  the  promontory. 
Sometimes  it  may  be  necessary  to  pierce  a  suture  or  fontanel. 
When  the  entire  width  of  the  perforator  has  entered  the  skull,  the 
blades  should  be  opened  in  different  directions,  so  as  to  enlarge 


Fig.  329. — Perforation  of  head  with  Simpson's  perforator:  right  hand  is  grasping 
handles  of  instrument.  The  t:ps  should  not  be  separated  until  after  they  have  entered 
the  fontanel. 


the  incision.  The  end  of  the  instrument  should  then  be  pushed 
into  the  skull  to  break  up  the  brain,  which,  mixed  with  fetal  blood, 
then  pours  out  of  the  perforation.  The  cranial  cavity  should  then 
be  thoroughly  washed  out  with  sterile  salt  solution. 

In  face  presentations  the  perforator  may  be  passed  into  the 
skull  through  the  orbit,  or  through  the  roof  of  the  mouth  behind 
the  posterior  nares. 

The  after-coming  head  should  be  perforated,  if  possible,  at 
some  point  behind  the  ear,  care  being  taken  that  the  perforator, 
which  must  necessarily  be  held  obliquely,  does  not  slip.  It  may, 
however,  be  sometimes  more  convenient  to  perforate  the  skull 
through  the  roof  of  the  mouth.  Cohnstein  has  advised  opening 
into  the  spinal  canal  in  the  neck,  in  order  that  a  metal  instrument 
may  be  passed  into  the  skull  to  break  up  the  brain  matter.  The 
author  has  sometimes  found  it  advisable  to  sever  the  head  from 


738 


EMBRYOTOMY. 


the  neck,  withdrawing  the  brain  matter  through  the  foramen 
magnum,  the  skull  being  then  broken  at  the  base. 

In  some  cases  the  head  collapses  sufficiently  after  perforation 
to  allow  it  to  be  born.  When  further  reduction  in  size  is  necessary, 
the  skull  must  be  broken. 

{B)  Head  ConiDiinution. —  i.  By  the  Craniotomy  Forceps. — 
Strong  forceps  have  long  been  used  for  breaking  away  the  skull  in 
small  pieces  around  the  perforation  internal  to  the  scalp,  which  is 
preserved  with  great  care.  The  process  is  tedious  and  may  be 
very  difficult.  It  should  not  be  employed  save  where  no  better 
appliances  are  at  hand. 

2.  By  the  Cranioclast. — This  instrument  was  introduced  by  Sir 
J.  Y.  Simpson  and  modified  by  Braun  ;  the  latter  form  is  the  more 
serviceable.     It  is  really  a  magnified   craniotomy  forceps.     One 


Fig.  330. — Craniotomy  on  after-coming  head  :  one  method  of  perforating. 


blade  is  fenestrated  and  is  meant  to  fit  outside  the  scalp  of  the 
head.  The  other  is  solid  and  is  meant  to  be  passed  through  the 
perforation  into  the  skull,  its  convexity  fitting  into  the  concavity 
of  the  outer  blade.  The  shanks  fit  together  by  a  button  lock,  and 
the  handles  may  be  approximated  by  means  of  a  screw  at  their 
ends.  When  the  instrument  is  used,  the  blades  are  applied 
separately,  the  solid  one  being  placed  inside  the  skull,  its  end 
reaching  the  base.  The  fenestrated  blade  is  then  placed  external 
to  the  skull,  being  fitted  to  the  other ;  the  screw  at  the  ends  of 
the  handles  is  then  turned  to  make  the  blades  grasp  the  skull 
firmly.  The  instrument  should  then  be  rotated  slightly  to  the 
right  and  left  alternately,  in  order  to  break  the  bone  that  is  held 
and  loosen  it  from  its  attachment.     The  skull  may  be  thus  treated 


CRANIOTOMY. 


739 


in  other  portions  around  the  perforation,  and  so  may  be  greatly- 
reduced  in  size. 

3.  By  the  Basilyst  or  Basiotribc. — In  a  small  percentage  of 
cases  the  cranioclast  cannot  reduce  the  base  of  the  skull  suffi- 
ciently to  permit  delivery.  Different  instruments  have  been  de- 
vised to  break  up  this  portion,  especially  the  basi-occipital  bone. 
One  of  the  earliest  forms  was  that  introduced  by  Lachapelle. 
Hubert  devised  an  instrument  for  piercing  the  sphenoid,  the 
operation  being  termed  "  spenatresia."  Guyon  used  a  couple  of 
trephines,  one  sliding  over  the  other. 

Tarnier's  basiotribe  consists  of  a  perforator,  tv/o  blades  of  un- 
equal length,  and  a  strong  compression  screws  at  the  ends  of  the 


Fig.  331.— Tarnier's  basiotribe. 


Fig.  332. — Tarnier's  basiotribe  (sepa- 
rate parts). 


handles.  When  used,  the  perforator  is  bored  through  the  vault 
and  into  the  base  of  the  skull.  The  blades  are  then  applied  to 
the  sides  of  the  skull,  locked,  and  made  to  crush  the  head  by 
means  of  the  compression  screw.  This  instrument  is  large  and 
difficult  to  manipulate.  Other  varieties  have  been  introduced, 
but  need  not  be  described  here. 

One  of  the  most  satisfactory  in.struments  is  A.  R.  Simpson's 
basily.st,  which  has  already  been  described  as  admirable  for  per- 
forating the  skull.  It  consists  of  two  halves,  whose  ends,  when 
close  together,  form  a  screw,  which  is  used  to  bore  into  the  bone. 
When  the  latter  is  sufficiently  penetrated,  the  handles  are  com- 


740 


EMBRYOTOMY. 


pressed,  in  order  to  separate  the  blades  and  fracture  the  bone. 
Attached  to  the  perforator  above  described  is  a  blade  that  is 
applied  external  to  the  skull,  so  that  a  strong  grasp  may  be 
taken.  It  may  thus  be  used  as  a  cranioclast  to  break  the  bones 
of  the  vault  around  the  perforation  and  in  extracting  the  head.  It 
possesses  an  advantage  over  the  cranioclast  in  being  at  the  same 
time  a  perforator  of  the  vault  and  base.  When  the  cranioclast  is 
used,  perforation  must  be  made  with  other  instruments. 

Though  the  base  of  .the  skull  may  be  broken  in  the  case  of  a 
markedly  contracted  pelvis,  it  is  inadvisable  to  carry  out  the  pro- 
cedure in  a  flat  pelvis  when  the  conjugate  is  less  than  2\  in.,  be- 
cause of  the  risk  to  the  maternal  tissues. 

4.  Cephalotripsy. — In  1 829  Baudelocque  introduced  the  cephalo- 


FlG.  333. — A.  R.  Simpson's  basilyst  tractor.  The  upper  figure  shows  entire  instru- 
ment:  a,  Basilyst  used  for  perforation  and  comminution  ;  b,  tractor  blade  to  be  applied 
to  skull  externally  when  entire  instrument  is  to  be  used  in  extracting  fetus. 

tribe,  a  long,  heavy  forceps  whose  handles  could  be  closed  by  a 
screw.  He  meant  the  instrument  to  be  used  without  previous 
perforation,  and  he  represented  that  it  could  crush  the  head, 
breaking  the  vault  and  base  within  the  scalp,  the  brain  matter 
being  forced  out  through  mouth,  nose,  and  eyes.  Chailly,  in 
1842,  advised  that  perforation  should  precede  cephalotripsy.  In 
recent  times  Sir  J.  Y.  Simpson,  Blot,  Scanzoni,  Hicks,  Lusk,  and 
others  have  devised  patterns  of  the  instrument. 

Cephalotripsy  is  not  to  be  compared  to  the  methods  already 
described  for  thorough  reduction  of  the  skull.  Von  Weber, 
Winckel,  and  others  have  shown  that  it  may  fail  to  crush  not 
only  the  base,  but  the  vault  as  well.     It  frequently  only  bends 


CRANIOTOMY. 


741 


and  distorts  the  bones.  When  the  instrument  is  used,  it  should 
be  appHed  after  perforation,  and  should  crush  the  head  in  different 
directions.     It  may  fail  to  grasp  the  head  firmly  after  crushing. 

5.  OtJier  Methods. — Cephalotomy,  the  removal  of  the  head  in 
segments,  has  been  recommended  by  various  authors.  Van 
Huevel's  saw  forceps  cuts  the  head  into  two  vertical  portions. 
Tarnier's  instrument  removes  a  wedge-shaped  piece.  The  wire 
ecraseur  has  been  used  to  cut  away  successive  parts  of  the  head. 
The  operation  has  never  been  widely  adopted ;  it  is  difficult  and 
dangerous  to  the  maternal  tissues  and  should  not  be  attempted. 


Fig.  334. — Coronal  section  of  head 
whose  base  has  been  perforated  with  the 
basilyst.  The  transverse  diameter  of  the 
reduced  skull,  in  front  of  the  ears,  meas- 
ured i\  in.  (A.  R.  Simpson). 


Fig.  335. — Head  compressed  by 
cephalotribe  (Simpson). 


{c)  Extraction. — The  advice  given  by  various  authors  that,  after 
reduction  in  size  of  the  head,  delivery  should  be  left  to  nature 
should  be  disregarded.  There  is  no  advantage  in  this  procedure 
and  several  disadvantages.  The  labor  may  be  delayed ;  the 
patient  may  be  much  distressed  on  coming  out  of  the  anesthetic 
to  find  that  her  troubles  are  not  over ;  and  in  the  downward 
progress  of  the  fetus  one  of  the  broken  bones  may  cut  the 
maternal  tissues.  Artificial  extraction,  slowly  and  cautiously  per- 
formed, should  always  follow  the  reduction  of  the  head.  It  may 
be  carried  out  in  several  ways  : 

I.  The  cranioclast  may  be  used  effectively  as  a  tractor  when 
the  skull  is  well  grasped.  It  should  grasp  the  occipital  end  of 
the  head  if  possible,  but  frequently  another  hold  must  be  taken. 
In  making  traction  the  curve  of  the  pelvic  canal  should  be  followed 


742 


EMBRYOTOMY. 


as  accurately  as  possible.  The  loosened  bones  should  not  be 
allowed  to  project  outside  of  the  scalp  and  cut  the  maternal  soft 
parts.  Traction  should  be  made  during  uterine  contractions,  or  at 
intervals  if  pains  be  absent.  If  the  thorax  and  abdomen  are  too 
large  for  the  birth  canal,  they  may  require  to  be  reduced  in  size 
after  the  head  is  partly  delivered. 

2.  The  basilyst  tractor  of  Simpson  also  serv^es  admirably  in 
extracting  the  head,  the  basilyst  portion  being  inside  the  skull  and 
the  traction  blade  outside.  Firm  compression  is  obtained  by 
means  of  a  screw  at  the  ends  of  the  handles. 


Fig.  336. — Tarnier's 
basiotribe  in  action ; 
perforator  being  in 
place,  as  is  also  first 
blade. 


Fig.  337. — First  blada  of 
basiotribe  has  crushed  occi- 
put, and  second  blade  is 
applied. 


iffllM'MX) 


Fig.  338. — Second  blade 
of  basiotribe  has  crushed 
sinciput. 


3.  Tarnier's  basiotribe  is  also  used  in  extraction,  but  it  is  less 
satisfactory  than  either  of  the  other  instruments  because,  while 
compressing  the  whole  head  in  one  direction,  it  enlarges  it  in 
another  at  the  same  time,  markedly  altering  its  plasticity. 

4.  The  cephalotribe  is  unsatisfactory  for  the  same  reasons. 
When  the  pelvic  contraction  is  considerable,  the  compressed  head, 
flattened  in  one  direction,  extended  in  another,  and  rigidly  held, 
cannot  be   moulded,  and  may  not  be  able  to  pass  along  the  canal 


CORPOREAL    EMBRYOTOMY.  743 

without  much   damage  to   the   maternal  tissues.     Moreover,  the 
blades  are  apt  to  sHp  if  the  delivery  be  difficult. 

5.  The  forceps  has  been  recommended  for  extraction  of  the 
head  after  perforation  in  cases  where  it  can  safely  be  used.  This 
procedure  is  not  advisable.  The  head  may  be  in  a  bad  position 
for  its  application  and  it  may  easily  slip. 

6.  Hooks  of  various  forms — e.  g.,  the  crotchet — were  formerly 
used  to  extract  the  head,  being  fastened  to  the  skull  inside  the 
perforation.  They  are  often  ineffective,  and  should  be  used  only 
when  no  better  instrument  is  at  hand.  They  may  easily  slip  and 
injure  the  maternal  tissues. 

7.  Version  has  been  recommended  by  some  authors  as  a 
means  of  delivery  and  condemned  by  others.  It  need  not  be 
employed  when  instrumental  extraction  is  possible.  It  should 
never  be  employed  when  the  condition  of  the  uterus  is  such  that 
its  walls  may  be  ruptured  or  damaged  by  the  manipulation. 
There  is  much  risk  that  spicules  of  bone  may  cut  the  uterus. 

Donald,  of  Manchester,  has  recommended  version  previous  to 
craniotomy,  in  order  that  perforation  of  the  skull  may  be  carried 
out  through  the  roof  of  the  mouth,  thus  msuring  that  the  base 
may  be  thoroughly  broken.  After  the  escape  of  the  brain  matter 
the  base  usually  bends  somewhat  on  itself  If  the  head  requires 
further  comminution.,  he  uses  a  cephalotribe.  Extraction  may  be 
carried  out  by  this  instrument  or  by  traction  on  the  body  and 
lower  part  of  the  fetus,  accompanied  by  suprapubic  pressure. 
Donald's  procedure  should  not  be  attempted  in  neglected  cases 
or  in  any  condition  in  which  considerable  risk  is  introduced  by 
performing  version.  It  might  be  particularly  valuable  in  cases  of 
rigid  cervix,  where  complete  dilatation  of  the  canal  cannot  be 
obtained. 

Corporeal  Embryotomy. — This  term  refers  to  the  reduc- 
tion of  the  body  of  the  child  by  mutilation  in  order  to  remove  it 
from  the  uterus.  In  ordinary  parlance  the  term  embryotomy  is 
limited  to  these  cases.  It  is  best,  however,  to  use  this  word  in  its 
widest  generic  sense,  and  to  consider  it  in  the  two  divisions — 
cephalic  embryotomy  (craniotomy)  and  corporeal  embryotomy. 

These  procedures  are  carried  out  in  transverse  cases  where 
turning  is  impracticable — e.  g.,  when  the  uterus  is  firmly  retracted 
on  the  fetus ;  when  the  retraction  ridge  is  elevated,  indicating 
stretching  of  the  lower  uterine  segment ;  and  when  the  shoulder 
is  impacted  in  the  pelvic  inlet.  In  cases  of  pelvic  contraction 
where  craniotomy  is  necessary  the  body  may  also  require  to  be 
broken  up.  Pathologic  enlargements  of  the  thorax  or  abdomen 
may  also  require  mutilation.  The  operation  may  also  be  neces- 
sary in  the  case  of  monstrosities.  Various  methods  have  been 
practised,  some  of  which  have  for  their  end  the  removal  of  the 
contents  of  the  body  ;  others  the  breaking  of  the  bony  skeleton. 


744 


EMBRYOTOMY. 


The  latter  are  the  most  efficacious.     The  choice  of  a  procedure 
must  often  depend  upon  the  position  of  the  fetus. 

Decapitation — When   the   neck  of  the   fetus   is  within   easy 
reach,  its  division  is  advisable  as  a  means  of  bringing  about  de- 


FlG.  339.— Braun's  hook. 

livery.  Decapitation  may  be  performed  in  various  ways.  One 
of  the  most  satisfactory  is  by  means  of  a  blunt  hook,  of  which 
the  angular  pattern  devised  by  Braun  is  the  best  (it  is  often 
termed    a  decollator).      In    using    this  instrument  the  first  two 

fingers  and  thumb  of  the  left 
hand  should  be  made  to  encircle 
the  neck  of  the  fetus,  drawing  it 
down  as  far  as  possible,  the  thumb 
being  placed  anteriorly.  If  an 
arm  prolapses  into  the  vagina,  it 
may  be  encircled  with  tape  and 
pulled  down  by  an  assistant. 
This  helps  to  steady  the  neck 
and  lower  it  somewhat.  The 
hook  should  be  passed  up  flat 
over  the  part  of  the  neck  situ- 
ated anteriorly,  and  should  be 
guided  by  the  fingers  into  posi- 
tion. When  the  angled  hook 
fits  the  neck,  the  handle  should 
be  pulled  downward  and  rotated 
from  side  to  side  several  times. 
In  this  m.anner  the  spinal  col- 
umn is  divided.  Round  hooks 
are  also  used  in  a  similar  way. 
Hooks  with  sharp  or  saw-toothed 
inner  edges  are  also  employed, 
but  they  have  no  advantages  over 
the  Braun  hook  and  are  more  apt 
to  injure  the  maternal  tissues.  A 
chain  ecraseur  or  simple  cord 
may  be  used  to  divide  the  neck, 
but  it  is  difficult  to  place  these 
in  the  proper  position.  Various 
instruments  have  been  devised  for  the  purpose  of  carrying  the  cord 
around  the  neck.  While  the  latter  is  being  divided,  the  maternal 
tissues  must  be  protected  from  the  movement  of  the  cord,  by  the 


Fig.  340. — Decapitation   with    Braun's 
hook. 


CLEIDOTOMY.  24^^ 

introduction  of  retractors  which  hold  the  vagina  open,  or  of  a 
tubular  speculum  through  which  the  cord  passes.  Occasionally, 
when  the  neck  is  within  easy  reach,  it  may  be  possible  to  divide 
it  M/ith  blunt-pointed  scissors,  the  ends  being  guided  by  fingers 
of  the  left  hand.  After  decapitation  the  trunk  may  be  pulled 
down  by  the  arm  if  it  be  prolapsed.  It  may  be  necessary  to 
pierce  the  upper  part  of  the  chest  with  a  cranioclast  or  basilyst 
tractor,  in  order  to  obtain  a  grasp  by  which  the  body  may  be 
pulled  down. 

The  head  should  next  be  delivered.  This  may  sometimes  be 
managed  by  suprapubic  pressure  and  traction  on  the  lower  jaw. 
Ordinarily  it  is  advisable  to  reduce  the  size  of  the  head  and  to 
deliver  it  with  a  cranioclast  or  some  other  form  of  extractor. 

Division  of  the  Spinal  Column. — When  the  back  of  the  fetus 
presents,  it  is  advisable  to  divide  the  spinal  column.  This  may  be 
carried  out  in  various  ways.  Various  forms  of  scissors  have  been 
devised,  to  which  the  names  of  spondylotome,  embryotome,  etc., 
have  been  applied.  Any  long,  strong  pair  of  surgical  scissors  or 
bone  forceps  suffices  for  the  purpose.  When  the  division  is  made, 
the  fetus  is  pushed  against  the  brim  by  an  assistant,  whose  hand 
is  on  the  abdomen.  After  the  column  is  cut  and  the  body  opened 
the  lower  section  is  pulled  downward  with  a  cranioclast  or  strong 
pair  of  forceps,  while  the  rest  of  the  body-wall  is  divided  trans- 
versely as  far  around  as  possible.  The  lower  half  is  then  deliv- 
ered, and  the  cranioclast  is  applied  to  the  body  wall  of  the  upper 
half,  in  order  to  deliver  it.  If  an  arm  is  in  the  way,  it  should  be 
amputated. 

Evisceration  or  Exenteration. — In  cases  of  labor  delayed  by 
large  size  of  the  abdomen  or  thorax  of  the  fetus,  caused  by 
pathologic  conditions,  it  may  be  necessary  to  open  these  cavities 
and  remove  the  viscera  before  the  fetus  can  be  extracted.  This 
procedure  may  also  be  carried  out  to  a  certain  extent  when  the 
body  is  reduced  in  size  by  division  of  the  spinal  column.  In 
transverse  cases  evisceration  alone  is  of  little  value  in  effecting 
delivery.  The  trouble  is  caused  by  the  head  and  vertebral  column, 
and  it  is  necessary  to  attend  to  these  and  not  to  the  soft  parts. 
In  the  rare  condition  of  presentation  of  the  anterior  surface  of 
the  body  in  an  impacted  transverse  case  it  may  be  necessary  to 
remove  the  viscera  and  part  of  the  chest-wall  before  the  neck  or 
spinal  column  can  be  reached.  In  some  cases,  by  performing 
cleidotomy  (division  of  the  clavicle),  it  may  be  possible  to  deliver 
the  fetus  without  interfering  with  the  body. 

Cleidotomy. — Within  recent  years  the  operation  of  cleidot- 
omy, or  division  of  the  clavicle,  has  been  recommended  in  various 
forms  of  delayed  labor  by  several  writers.  It  was  first  advocated 
by  H.  R.  .Spencer,  of  England,  in  1895,  who  employed  it  in  certain 
cases  of  impaction   of  the  trunk  of  the  fetus.     Cases  have  since 


74^  .  EMBRYOTOMY. 

been    reported  by  Phanomenoff,  Knorr,  Strassmann,  Ballantyne, 
and  others. 

Indications. — These  cannot  as  yet  be  well  defined.  Ballan- 
tyne, describing  the  operation  in  1901,  says  that  it  has  hitherto 
been  carried  out  only  on  the  dead  fetus,  but  that  there  is  no  good 
reason  why  it  might  not  be  performed  on  the  living  fetus  in  some 
circumstances.  The  great  indication  is  disproportion  between  the 
size  of  the  shoulders  and  the  genital  canal.  Ballantyne  describes 
various  conditions,  as  follows  : 

1.  Broad-shouldered  fetus. 
{a)  Normal-sized  head. 
{b)  Large  head. 

{c)  Anencephalic  head. 
In  the  first  and  third  of  these  cleidotomy  may  alone  be  suffi- 
cient ;   in  the  second  it  is  accessory  to   a  destructive  operation 
on  the  head. 

2.  Contracted  pelvis. 
{a)  Justominor. 

\b)  Flat. 

(r)  Kyphotic. 
In  the  first  and  second  cleidotomy  is  needed  at  the  brim ;  in 
the  third  at  the  outlet.     In  all  three  it  will  doubtless  be  preceded 
by  reduction  of  the  size  of  the  head. 

3.  Broad-shouldered  fetus  in  contracted  pelvis,  neither  being 
excessive. 

4.  Impacted  shoulders  in  breech  cases. 

5.  Danger  from  eclampsia,  threatened  uterine  rupture,  etc., 
necessitating  rapid  delivery. 

Operation. — The  clavicle  is  best  divided  with  a  pair  of  long, 
straight  scissors.  The  index  and  middle  fingers  of  the  left  hand 
are  passed  along  the  anterior  surface  of  the  fetus,  whose  head  or 
neck  has  been  born,  until  the  ridge  of  the  clavicle  is  felt.  The 
right  hand  holds  the  scissors  and  directs  it  upward  until  it  touches 
the  middle  of  the  clavicle  or  a  point  nearer  the  sternal  end.  The 
bone  and  the  skin  over  it  are  then  divided.  If  necessary,  the 
other  clavicle  is  cut  in  the  same  manner.  This  procedure  results 
in  a  reduction  of  the  bisacromial  circumference,  the  cut  ends  of 
the  bones  overriding.  Ballantyne  found  that  the  circumference 
of  a  dead  infant  which  measured  27  cm.  was  reduced  to  23  cm. 
with  one  clavicle  divided,  and  22  cm.  with  both  divided.  This 
author  points  out  that  there  is  little  danger  of  injuring  the 
maternal  tissues  or  the  subclavian  vessels  of  the  fetus  if  care  be 
exercised. 


INDEX. 


Abdomen,  distention  of,  differentiation  of, 
from  advanced  pregnancy,  127 
enlargement  of,  in  ectopic  pregnancy, 41 2 
of  fetus,  distention  of,  526 
size  and  shape  of,  as  signs  of  pregnancy, 
118 
Abdominal  hysterectomy,  total,  720 
signs  of  pregnancy,  1 17 
stalk,  28 

importance  of,  28 
swellings  complicating  labor,  439 
wall  in  puerperium,  259 
Ablatio  placentae,  556 

Csesarean  section  for,  723 

differential  diagnosis  of,  561 

treatment  of,  562 
Abortion,  357,  659 
complete,  361 

treatment  of,  369 
differential  diagnosis  of,  365 
duration  of,  359 
etiology  of,  357 
frequency  of,  357 
habitual,  362 
incomplete,  361 

treatment  of,  369 
indications  for,  659 
inevitable,  361 

treatment  of,  368 
mechanism  of,  359 
methods  of,  660 

during  first  three  months,  661 

from  third  to  sixth  month,  662 
missed,  362 

treatment  of,  370 
molar,  362 
results  of,  364 
symptoms  of,  358 
threatened,  360 

treatment  of,  367 
tubal,  403 


Abscess  of  vulva  during  pregna-ncy,  320 

in  labor,  436 
Acardiac  monster,  135 
Accouchement  force,  722 
Acute   yellow  atrophy  during   pregnancy, 

299 
Adams-Alexander  operation  for  retrover- 
sion, effect  of,  on  pregnancy,  337 
Adipocere     transformation     of     embryo, 

407 
^quibiliter  justo-raajor  pelvis,  453 

justo-minor  pelvis,  450 
After-pains,  268 
Air-infection  after  labor,  245 
Albuminuria  during  pregnancy,  312 

causes  of,  314 
Alimentary  canal  in  eclampsia,  383 
in  puerperium,  265 
functions  of  fetus,  84 
Allantois,  29 
Amnion,  development  of,  60 

dropsy  of,  340.      See  Hych-amnion. 
false,  formation  of,  27 
formation  of,  27 
in  ectopic  pregnancy,  410 
Amniotic  adhesions,  344 
Anatomy  of  fetus,  71.     See  Fetus. 
Anemia  after  labor,  602 
Anencephalus,  537 
Anesthesia  in  labor,  245 

spinal,  with  cocain,  246 
Anteroposterior    conjugate,    measurement 

of,  447 
Anteversion  of  pregnant  uterus,  332 

treatment  of,  333 
Antisepsis  in  obstetrics,  240 
Anus  vaginalis  in  labor,  437 
Apoplexies,  placental,  353 
Apparatus,  cleansing   of,  for  labor   cases, 

243 
Appendicitis  during  pregnancy,  336 

747 


748 


INDEX. 


Areola  as  sign  of  pregnancy,  Ii6 

secondary,  as  sign  of  pregnancy,  117 
Arteries  during  pregnancy,  290 
Ascites,  differentiation  of,  from  advanced 

pregnancy,  127 
Asepsis  in  obstetrics,  240 
Asphyxia  neonatorum,  625 
treatment  of,  626 

Buist's  method,  626 

by  direct  insufflation,  628 

by  intubation  of  larynx,  627 

Byrd's  method,  627 

Schultze's  metliod,  626 

Sylvester's  method,  627 
Asthma  during  pregnancy,  296 
Atrophy,  acute  yellow,  during  pregnancy, 

299 
Autoinfection  in  puerperium,  638 
Auvard's  combined  perforator,  cranioclast, 

and  cephalotribe,  736 
Axilla,  hypertrophy  of  skin  glands  in,  after 

labor,  620 
Avers"  method  of  symphysiotomy,  729 

Bacillus  aerogenes  capsulatus  in  puerpe- 
ral infection,  636 

diphtherise  in  puerperal  infection,  63 ^ 
Bacteria  of  eclampsia,  391 
Bacteriology  of  vagina  in  pregnancy,  ill 
Bag  of  membranes,  149 

of  waters,  149 
Ballottement  to  determine  pregnancy,  1  25 
Bandl's  ring,  178 
Basilyst,  Simpson's,  739 
Basiotribe,  Tarnier's,  739 
Bauchstiel,  28 
Baudelocque's  diameter,  measurement  of, 

445 

method  in  face  presentation.  500 
Bilaminar  stage,  23 
Birth  of  fetus,  changes  after,  82 
Bladder,  distended,  differentiation  of,  fiom 
early  pregnancy,  126 

distention  of,  in  labor,  437 

during  labor,  170 

in  puerperium,  257 

of  fetus  at  term,  79 
Blastoderm,  trilaminar,  24 
Blastodermic  vesicle,  22 


Blastodermic  vesicle,  bilaminar  stage  of,  23 

blastula  stage  of,  22 
Blighted  ovum,  362 
Blood  during  pregnancy,  107,  290 

in  newborn,  ?st, 

in  puerperium,  167 
Blood-clots,  retention  of,  604 
Blood-vessels  of  fetus  at  term,  78 
Bony  pelvis,  1S4 

Brain,  injuries  of,  in  newborn,  625 
Braun's  cranioclast,  735 

hook,  decapitation  with,  744 

trephines,  straight  and  curved,  734 
Breasts,  anomalies  of,  614 

care  of,  275 

during  pregnancy,  141 

changes  in,  in  ectopic  pregnancy,  41 1 
in  pregnancy,  116 
Breus'  axis-traction  forceps,  6S3 
Broad  ligaments  in  puerperium,  258 
Bronchitis  during  pregnancy,  295 
Buhl's  disease  in  newborn,  630 
Buist's  method  of  artificial  respiration,  626 
Byrd's  method  of  artificial  respiration,  627 

C.«SARFAN  section,  710 
conservative,  712 

and  sterilization,  718 
indications  for,  712 
technique  of,  715 
time  for,  715 
for  rapid  delivery,  722 
history  of,  710 
in  ablatio  ]3lacentse,  723 
in  affections  of  heart,  lungs,  etc.,  723 
in  articulo  mortis,  723 
in  eclampsia,  722 
in  placenta  preevia,  722 
Porro's,  711 
pregnancy  after,  718 
vaginal,  721 
Calcification  of  embryo,  407 
Calculus  in  bladder  in  labor,  438 
Cancer  of  cervix  in  labor,  435 
Caput,  primary,  215 
secondary,  215 
succedaneum,  215 
Carcinoma  c-f  rectum   during   pregnancy, 
337 


INDEX. 


749 


Carcinoma  uteri  during  pregnancy,  327 
diagnosis  of,  327 
treatment  of,  328 
Caries  of  teeth  during  pregnancy,  298 
Catalepsy  during  pregnancy,  2S9 
Cells  of  Rauber,  22 
Celom,  formation  of,  26 
Cephalhematoma,  621 
Cephalotripsy,  74° 

Cervical  polypi  during  pregnancy,  328 
Cervix,  anomalies  of,  in  labor,  432 

at  beginning  of  puerperium,  249 

atresia  of,  in  labor,  432 

canalization  of,  during  labor,  164 
mechanism  of,  183 

cancer  of,  in  labor,  435 

changes  in,  in  pregnancy,  97 

dilatation  of,  667 
during  labor,  148 

displacement  of,  in  labor,  432 

impaction  of,  in  labor,  434 

in  lal^or,  164 

lacerations  of,  583 

polypi  of,  during  pregnancy,  328 

relaxation  of,  183 

rigidity  of,  in  labor,  433 

uteri,  lesions  of,   puerperal  infection  in, 
642 

wounds  in,  605 
Chamberlen's  forceps,  680 
Cholera  during  pregnancy,  303 
Chorda  dorsalis,  25 
Chorea  gravidarum,  287 
Chorio-epithelioma  malignum  as  cause  of 
hemorrhage,  605 
relation  of,  to  pregnancy,  606 
treatment  of,  609 
Chorion,  development  of,  48 

frondosum,  development  of,  51 

in  ectopic  pregnancy,  410 

Ireve,  development  of,  53 
Chorionic  membrane,  formation  of,  27 
Circulation  of  fetus,  81 
Clear  jjrotoplasm,  17 
Cleavage  cavity,  22 

nucleus,  21 
Cleidotomy,  745 
Cocain  in  spina!  anesthesia,  246 
Colon  bacillus  in  ])uerperai  infection,  635 


Colon,  distended,  in  labor,  437 
Conception,  17 
Conjugata  diagonal  is,  447 
Constipation  during  pregnancy,  299 
Contraction  ring,  178 

in  labor,  164 
Cord,  umbilical,  prolapse  of,  529 

rupture  of,  529 

short,  522 
Cornil  and  Ranvier's  tlieory  of  eclampsia, 

385 
Corona  radiata,  17 
Corporeal  embryotomy,  743 
Corpus  albicans,  18 
luteum,  false,  18 
of  pregnancy,  18 
true,  18 
Cough  during  pregnancy,  295 
Cranioclast,  Braun's,  735 
Craniotomy,  734 

extraction  of  fetus  after,  741 
forceps  of  Meigs,  735 
indications  for,  734 
method  of,  736 

by  head  comminution,  738 
Ijy  perforation,  736 
prognosis  of,  735 
Crede's    method    of   placental    expulsion, 

237 
Crenasol  for  antiseptic  wash,  242 
Cyanosis  neonatorum,  83 
Cyst  of  placenta,  353 

vulvar,  during  pregnancy,  320 
Cystic  mole,  345.      See  Hydaiidiform  de- 
generation. 
swellings  of  vulva  and  vagina   in  labor, 
437 
Cystitis  during  pregnancy,  310 

in  puerperium,  611 
Cystocele  in  labor,  437 

Decidua,  absorption  of,  44 
nature  of  changes  in,  42 
mechanical,  42 
non-mechanical,  43 
reflexa,  35 

in  ectopic  pregnancy,  409 

origin  of,  Peters's  view,  36 

relations  between  ovum  and,  45 


750 


INDEX. 


Decidua  serotina,  38 

in  ectopic  pregnancy,  408 
tuberose     subchorionic    hematoma    of, 

362 
vera,  30 
Deciduitis,  352 
Deciduoma  benignum,  364 
Degeneration,  fatty,  of  placenta,  352 

fibrous,  of  placenta,  351 
Delivery,  method  of  approximating    date 

of,  131 
Dermatitis  exfoliativa  of  newborn,  631 
Descent  in  labor,  208 
Deutoplasm,  17 
Diabetes  insipidus  during  pregnancy,  310 

mellitus  during  pregnancy,  311 
Diaphragm  of  fetus  at  term,  78 
Diarrhea  during  pregnancy,  299 
Diastasis  of    recti   abdominis  muscles   in 

pregnancy,  593 
Digestion  in  pregnancy,  109 
Diphtheria  during  pregnancy,  306 
Discus  proligerus,  17 

Doderlein's  bacteriology  of  eclampsia,  391 
Dolores  presagientes,  147 
Dropsy   of  amnion,    340.      See   IJydrain- 
nion. 
of  villi,   345.      See    Hydatidiform    de- 
generation. 
Dubois'  forceps,  682 
Dyspnea  during  pregnancy,  295 
Dystocia,  prevention  of,  490 

Eclampsia,  370 

alimentary  canal  in,  383 
bacteriology  of,  391 
blood  in,  390 
Cesarean  section  for,  722 
causes  of,  384 

Angus  Macdonald's  theory,  386 

Cornil  and  Ranvier's  theory,  385 

Frierichs'  theory,  385 

Halbertsma's  theory,  386 

Ries'  theory,  387 

Stumpfs  theory,  387 

Traube's  theory,  385 
central  nervous  system  in,  383 
condition  of  patient  after,  375 
diagnosis  of,  375 


Eclampsia,  edema  in,  380 
effect  of,  on  fetus,  384 
frequency  of,  370 
heart  in,  383 
kidneys  in,  380 
labor  in,  375 
liver  in,  382 
lungs  in,  -^^-^ 

mortality  of  fetus  from,  379 
nature  of,  384 
pathology  of,  379 
placenta  in,  384 
premature  labor  in,  394 
prognosis  of,  376,  378 
recurrence  of,  372 
stage  of  clonic  spasms  of,  374 
of  invasion  of,  373 
tonic  convulsions  of,  373 
statistics  of,  371,  377 
symptomatology  of,  372 
thyroid  in,  392 
treatment  of,  393 
during  attack,  375 
preventive,  393 
urinary  system  in,  379 
urine  in,  388-393 
uterus  in,  383 
Ectopic   pregnancy,  397.     See   also  Preg- 
nancy, ectopic. 
Edema  during  pregnancy,  291 
in  eclampsia,  380 
of  fetus,  527 
of  placenta,  350 

of  vulva  and  vagina  in  labor,  436 
during  pregnancy,  321 
Egg  plasm,  17 

Embolism,  air,  after  labor,  600 
pulmonary,  after  labor,  599,  602 
systemic,  after  labor,  602 
Embryo,  adipocere  transformation  of,  407 
calcification  of,  407 
delimitation  of,  26 
formation  of  vitelline  duct  in,  27 
intestinal  canal  of,  formation  of,  27 
mummification  of,  406 
Embryonal  area,  23 
Embryotomy,  7.33 

corporeal,  743 
Embryulcia  in  pelvic  presentation,  514 


INDEX. 


751 


Emphysema  during  pregnancy,  296 
Endocarditis  during  pregnancy,  292 
Endocervicitis,      chronic,      during     preg- 
nancy, 323 
Endometritis,   chronic,  during  pregnancy, 

323 

Endothelium,  maternal,  57 

Enterocele,  vaginal,  in  labor,  437 

Epiblast,  23 
fetal,  57 

Epilepsy  during  pregnancy,  287 

Erysipelas  during  pregnancy,  306 

Evisceration,  745 

Evolutio  conduplicato  corpore,  519 

Evolution,  spontaneous,  in  transverse  pres- 
entation, 519 

Exenteration,  745 

Exomphalos  of  fetus,  527 

Exophthalmic    goiter    during    pregnancy, 
289 

Expulsion  of  trunk  in  labor,  213 

Extension  in  labor,  212 

External  conjugate,  measurement  of,  444 
genitals  of  fetus  at  term,  80 

Fallopian  tubes  in  pregnancy,  105 

lesions    of,    puerperal    infection     in, 

644 
of  fetus  at  term,  80 
False  corpus  luteum,  18 
Female  pronucleus,  19 
Fertilization  of  ovum,  nature  of,  21 

place  of,  20 
Fetal  epiblast,  57 

shock  as  sign  of  pregnancy,  123 
Fetus,  adhesion  of  membranes  to,  528 
alimentary  functions  of,  84 
anatomy  of,  71 
anomalies  of,  491 
at  term,  head  of,  199 

head  of,  fontanels  of,  200 
measurements  of,  200 
mobility  of,  on  trunk,  202 
protuberances  on,  200 
sutures  of,  199 
obstetrically  considered,  199 
peculiarities  of,  76 
in  bladder,  79 
in  diaphragm,  78 


Fetus    at    term,    peculiarities    of,    in    ex- 
ternal genitals,  80 

in  Fallopian  tubes,  80 

in  head,  76 

in  heart  and  blood-vessels,  78 

in  kidneys,  79 

in  liver,  78 

in  lungs,  78 

in  ovaries,  80 

in  stomach,  78 

in  suprarenal  bodies,  79 

in  thymus,  78 

in  umbilicus,  79 

in  urethra,  79 

in  uterus,  79 

in  vagina,  80 
trunk  of,  202 
attitude  of,  at  beginning  of  labor,  202 
blood  of,  at  birth,  83 
calcification  of,  407 
changes  in,  after  birth,  82 
circulation  of,  81 
dead,  523 

death  of,  in  ectopic  pregnancy,  415 
influence  of,  on  albuminuria  of  preg- 
nancy, 316 
development  of,  twenty-first  day  to  term, 

71-73 
distention  of  abdomen  of,  526 
division  of  spinal  column  in,  745 
edema  of,  527 
effect  on,  of  carcinoma  uteri,  327 

of  eclampsia,  384 

of  nephritis,  maternal,  317 

of  syphilis,  maternal,  307 
and  paternal,  308 
paternal,  307 

of  vaccination  of  mother,  305 
enlarged  thorax  of,  525 
erysipelas  of,  306 

excessive  ossification  of  skull  of,  523 
exomphalos  of,  527 
expulsion  of,  151 

extraction  of,  after  craniotomy,  741 
function  of  placenta  regarding,  86 
glycogenic  functions  of,  86 
heart    sounds  of,  as  sign   of  pregnancy, 

121 
heat  production  of,  84 


752 


INDEX. 


Fetus,  hernia  of,  527 
hydrocephalus  of,  524 
hydromeningoceie  of,  525 
hydiorrhachis  of,  527 
large,  523 
malaria  of,  304 
malpositions  of  head  of,  491 
measles  of,  305 
mensuration  of,  to   determine   stage  of 

pregnancy,  132 
mortality  of,  from  eclampsia,  379 
moulding  of,  in  pelvic  presentation,  506 
movements  of,  as   signs  of  pregnancy, 
121 
in  ectopic  pregnancy,  412 
nervous  system  of,  86 
nutrition  of,  80 
physiology  of,  80 
position  of,  205 

occipito-anterior,  206 
presentation  of,  203 
prolapse  of  limbs  of,  521 
relation  of  umbilical  cord  to,  71 
renal  functions  of,  85 
respiration  of,  Si 
scarlatina  of,  304 
septicemia  of,  306 
size  of,  73 
small,  523 
small-pox  of,  305 
table  of  progressive  size,  75 
transmission    of    diseases    to,    through 
placenta,  87 
of  diseases  to  mother  from,  88 
of  syphilis  to,  307 
of  typhoid  to,  304 
tumors  of,  527 
version  of.  669 
viability  of,  129 
waste  products  of,  in  causation  of  albu 

minuria  of  pregnancy,  316 
weight  of,  75 
Fibromyoma  of  uterus  in  labor,  430 
during  pregnancy,  324 
diagnosis  of,  325 
symptoms  of,  325 
treatment  of,  326 
Fibromyxoma  telangiectodes,  353 
Fibrous  mole,  362 


Finger-nails,  loosening    of,   during    preg- 
nancy, 319 
First  polar  body,  19 
Flexion  in  labor,  209 
Foetus  papyraceus,  135 
Forceps,  678 

application  and  use  of,  696 
in  high  operation,  700 
in  low  operation,  706 
axis-traction,  467,  688 
Breus',  683 
Milne  Murray's,  690 
adjustable,  692 
Tarnier's,  681 
Chamberlen's,  680 
compensation-curve,  688 
craniotomy,  of  Meigs,  735 
Dubois',  682 
for  abnormal  pelvis,  692 
for  normally  curved  pelvis,  690 
functions  of,  695 
Hermann's,  683 
history  of,  678 
Hubert's,  687 
indications  for  use  of,  694 
locks  for,  French  and  English,  684 
long  or  curved,  687 

use  of,  707 
Pajot's  maneuver  with,  68S 
principles  of,  6S4 
Simpson's,  684 
straight  or  short,  685 
use  of,  708 

with    Reynold's  traction  hooks,  685 
Fracture  of  bones  in  newborn,  623 

of  pelvic  bones,  593 
Frierichs'  theory  of  eclampsia,  3S5 
Funic  souffle  as  sign  of  pregnancy,  123 

Galactocele,  615 

Galactorrhea,  614 

Gangrene,  puerperal,  614 

Gastro-elytrotomy,   720 

Generation,  17 

Genitalia,  care  of,  during  pregnancy,  141 

external   inflammation   of,  during  preg- 
nancy, 320 
Germinal  spot,  17 

vehicle,  17 


INDEX. 


753 


Gingivitis  during  pregnancy,  298 
Glycogenic  function  of  fetus,  86 
Glycosuria  during  pregnancy,  31 1 
Goiter,  exophthalmic,   during   pregnancy, 

289 
Gonococcus  in  puerperal  infection,  635 

Halbertsma's  theory  of  eclampsia,  386 
Head,  moulding  of,  in  brow  presentation, 
502 

of  fetus  at  term,  76 
Head-moulding  in  occipito-anterior  cases, 

214 
Heart  disease  in  labor,  595 

during  pregnancy,   291 

in  eclampsia,  383 

in  pregnancy,   108 

of  fetus  at  term,  78 
Heat  production  of  fetus,  84 
Hegar's  sign  of  pregnancy,  124 
Hematocele  and  hematoma    in  diagnosis 

of  ectopic  pregnancy,  417 
Hematoma  after  labor,  592 

hemorrhage  from,  605 

of  vagina  in  labor,  436 

of  vulva  in  labor,  436 
during  pregnancy,  320 
Hematometra,     differentiation     of,     from 

early  pregnancy,  1 26 
Hematuria  during  pregnancy,  310 
Hemicephalus,  537 
Hemoglobinuria  of  newborn,  630 
Hemoptysis  during  pregnancy,  296 
Hemorrhage,  accidental,  556 

from  genital  tract  during  pregnancy,  323 

in  third  stage  of  labor,  565 

postpartum,  565 

puerperal,  603 

causes  of,  603-605 
Hensen's  node,  24 

Hepatic  toxemia  during  pregnancy,  299 
Hermann's  forceps,  683 
Hernia  during  pregnancy,  333 

in  labor,  429 
femoral,  439 
inguinal,  439 

of  fetus,  527 

of  umbilical  cord,  356 

umbilical,  in  newborn,  629 

48 


Herpes  during  pregnancy,  319 

gestationis,  319 
Hetero  infection  in  puerperium,  637 
Hirst's  measurement  of  pelvis,  450 
Holoblastic  segmentation,  22 
Hubert's  forceps,  687 
Humphrey's  method  in  face  presentations, 

500 
Hydatid  cyst,   differentiation  of,  from  ad- 
vanced pregnancy,  128 
mole,  345.      See  Hydatidiform   degen- 
eration. 
Hydatidiform  degeneration,  345 
differential  diagnosis  of,  349 
etiology  of,  347 
results  of,  347 
symptoms  of,  348 
treatment  of,  349 
Hydramnion,  340 

differential  diagnosis  of,  343 
frequency  of  occurrence  of,  340 
influence  of,  on  labor,  343 

on  pregnancy,  343 
pathology  of,  340 
prognosis  of,  343 
symptoms  of,  342 
treatment  of,  343 
Hydrocephalus  of  fetus,  524 
Hydi"omeningocele  of  fetus,  525 
Hydrorrhachis  of  fetus,  527 
Hydrorrhoea  gravidarum,  322 
Hyperlactation,  615 

Hypertrophy  of  vaginal  wall  during  preg- 
nancy, 321 
Hypoblast,  23 

Hysterectomy,  abdominal,  total,  720 
Hysteria  during  pregnancy,  289 
Hysteropexy,  labor  after,  430 

Icterus  in  newborn,  629 

Impetigo  herpetiformis  during  pregnancy, 

319 
Incarceration  of  uterus  during  pregi^ancy, 

329 

treatment  of,  332 
Incontinence  of  urine  during  pregnancy, 

310 
Incubation,  279 
Incubator,  De  Lee's,  281 


754 


INDEX. 


Inertia  uteri,  424 
Infant  incubation,  279 
newborn,  621 

asphyxia  of,  625.    See  also  Asphyxia 

neonatorum. 
Buhl's  disease  of,  630 
cephalhematoma  of,  621 
fractures  in,  623 
hemoglobinuria  of,  630 
icterus  in,  629 

indentations  on  skull  of,  622 
injuries  of  brain  in,  625 
of  muscles  in,  623 
of  nerves  in,  624 
omphalorrhagia    of,    629.     See  also 

Omphalorrhagia  neonatortan. 
ophthalmia  of,  630 
septic     infection     of    umbilicus    in, 

628 
skin  diseases  of,  631 
tetanus  of,  630 
umbilical  hernia  in,  629 
Infarcts,  placental,  66,  353 
Inflammation,        intraperitoneal,       during 
pregnancy,  335 
of  placenta,  352 

of  uterus  during  pregnancy,  323 
Influenza  during  pregnancy,  303 
Insanity,  613 

during  pregnancy,  286 
Instruments,  cleansing  of,  for  labor  cases, 

243 

Intercotyledonary  septa  of  Bumm,  58 

Intervillous  circulation  and  vessels  of  mu- 
cosa, relations  between,  55 
physics  of,  59 
spaces,  65 

Intestinal   canal  of  embryo,  formation  of, 
27 
obstruction  during  pregnancy,  337 

Intestines,  lesions  of,  in  puerperal    infec- 
tion, 645 

Intraperitoneal   inflammation  during  preg- 
nancy, 335 

Intra-uterine  pressure,  107 

Inversion  of  uterus,  588 

Involution  of  uterus  in  puerperium,  260 

Jaundice  during  pregnancy,  299 


Keratolysis  of  newborn,  631 
Kidneys,  displaced,  in  labor,  439 

during  pregnancy,  311 

in  eclampsia,  380 

of  fetus  at  term,  79 
Kyphoscoliosis,  486 
Kyphosis,  480 

in  pregnancy,  483 

Labor,  145 

abdominal  swellings  in,  439 

abscess  of  vulva  in,  436 

accessory  muscles  in,  151 

advance  of  head  in,  152 

after  hysteropexy,  430 

air  embolism  after,  600 

air-infection  after,  245 

anemia  after,  602 

anesthesia  in,  245 

spinal,  with  cocain,  246 

anomalies  of  accessory  muscles  in,  427 

of  cervix  in,  432 

of  vulva  and  vagina  in,  435 
anus  vaginalis  in,  437 
apparatus  for,  cleansing  of,  244 
atresia  of  cervix  in,  432 
bladder  in, 170 
bowel  complications  in,  437 
calculus  in  bladder  in,  438 
cancer  of  cervix  in,  435 

of  rectum  in,  437 
causes  of,  174 
cervix  in,  164 
chamber  for,  224 
classification  of,  146 
cleansing  instruments  for,  243 

of  patient,  244 
clinical  phenomena  of,  I46 
collapse  in,  600 
complex,  539 
conduct  of,  224 
contracted  pelvis  in,  440 
contraction  ring  in,  164 
contractions  of  uterus  during,  177 
cystic  swellings  of  vulva  and  vagina  in, 

437 
cystocele  in,  437 

defective  uterine  contractions  in,  424 
delay  in,  from  pelvic  presentation,  507 


INDEX. 


755 


Labor,  delayed,  424 

delimitation  of  os  internum  in,  164 
delivery  of  body,  232 

of  placenta  after,  155 
diastasis  of  recti  abdominis  muscles  in, 

593 
differentiation    of   uterine  wall    during, 

160 
dilatation  of  cervix  during,  148 
displaced  kidney  in,  439 
distended  bladder  in,  437 
colon  in,  437 
rectum  in,  437 
duration  of,  155 

edema  of  vulva  and  vagina  in,  436 
effect  of  pain  in,  152 
excessive  expellant  powers  of,  423 
expulsion  of  fetus,  151 
femoral  hernia  in,  439 
fibromyoma  of  uterus  in,  430 
first  stage  of,  147 

care  of  patient  in,  228 

obstetrician's  duties  in,  227 
form  and  size  of  uterus  during,  156 
formation  of  bag  of  membranes  during, 

149 
fractures  of  pelvic  bones  in,  593 
funnel-shaped  pelvis  in,  454 
hand-cleansing  for,  241 
hardening  of  uterus  during,  176 
heart  disease  in,  595 
hematoma  after,  592 

of  vulva  and  vagina  in,  436 
hernia  in,  429 

hydrocephalus  of  fetus  in,  524 
hydromeningocele  of  fetus  in,  525 
hypertrophy   of  skin    glands    in    axilla 

after,  620 
immediate  duties  of  physician  after,  239 
impaction  of  cervix  in,  434 
in  brow  presentation,  501 
in  deep  pelvis,  455 
in  eclampsia,  375 
in  face  presentations,  497 
in  malacosteon  pelvis,  478 
in  mento-anterior  presentation,  497 
in  mento-posterior  presentation,  498 
:n  mother  with  tabes  dorsalis,  177 
in  normally  contracted  pelvis,  452 


Labor  in  obliquely  contracted  pelvis,  475 
in  occipitoposterior  cases,  492 

abnormal,  493 

forceps  in,  495 
in  old  primiparse,  430 
in  pelvic  presentations,  505 

complications  of,  508 

constriction  of  fetus  by  uterus,  512 

displacement  of  arms,  510 

embryuloa  in,  514 

forceps  in,  514 

impaction  of  breech,  509 

impaction  of  head,  512 

malrotation  of  head,  515 

manual  extraction,  512 

Mauriceau  grasp  in,  514 

non-engagement  at  brim,  508 

Prague  grasp  in,  513 

Smellie  grasp  in,  512 

Smellie-Veit  grasp  in,  514 

Wigand-Martin  method  in,  514 
in  rickety  flat  pelvis,  463 
in  shallow  pelvis,  455 
in  transverse  presentation,  520 
in  transversely  contracted  pelvis,  476 
infection  after,  241 
influence   on,   of   cerebrospinal   nerves, 

175 

of  diet,  490 

of  hydramnion,  343 

of  uterine  malformation,  428 

of  uterine  malposition,  428 
inguinal  hernia  in,  439 
irregular  uterine  contractions  in,  426 
justo-major  pelvis  in,  454 
kyphosis  in,  483 
laceration  of  cervix  in,  583 

of  perineum  in,  586 

of  vagina  in,  584 
masculine  pelvis  in,  455 
mechanism  of,  208 

expulsion  of  trunk,  213 

extension,  212 

external  rotation,  2K2 

flexion,  209 

in  occipitodextra  anterior  cases,  214 

internal  rotation,  210 

restitution,  212 
movements  in  pelvic  floor  during,  170 


756 


INDEX. 


Labor,  non-rachitic  pelvis  in,  455 

normal,  anatomy  and  physiology  of,  156 
nurse  in  cases  of,  224 

outfit  of,  225 
occlusion  of  os  externum  in,  432 
ovarian  tumors  in,  438 
pelvic  floor  in,  169 
physician's  outfit  for  cases  of,  226 
physiology  of,  174 
precipitate,  423 
premature,  357,  663 

from  accidental  hemorrhage,  560 

in  eclampsia,  394 

methods  of  inducing,  664 
preparation  of  bed  for,  225 

of  patient  for,  225 
prolapse  of  fetal  limbs  in,  521 
prolapsus  uteri  in,  429 
pulmonary  embolism  in,  599 
relation  of  monsters  to,  538 
rigidity  of  cervix  in,  433 

of  vagina  in,  435 

of  vulva  in,  435 
rupture  of  air-passage  in,  595 

of  membranes  during,    150 

of  pelvic  joints  in,  592 

of  sacro-iliac  joints  in,  593 

of  uterus  in,  575 
sacculation  in,  429 
scoliosis  in,  4S5 
second  stage  of,  151 

care  of  perineum,  230 
management  of,  229 
spondylolisthesis  in,  472 
spurious,  413 
third  stage  of,  155 

expression  of  placenta,  235 
hemorrhage  in,  565 
management  of,  235 
tissues  outside   genital   passage  during, 

172 
tumors  of  vulva  and  vagina  in,  437 
twin,  533 

complex,  536 

conduct  of,  535 
urethra  during,  170 
uterine  contractions  in,  147 
uterus  during,  175 
vagina  in,  168 


Labor,  vaginal  enterocele  in,  437 

varicose  veins  of  vulva  and  vagina  in, 

436 
Lactation,  276 
Langhans'  layer,  49 
Law  of  polarity,  184 
Ligamentum  arteriosum,  %T) 
Lineje    albicantes    as   sign   of  pregnancy, 

118 
Liquor  amnii,  89 

character  of,  89 
sources  of,  89 
uses  of,  90 
folliculi,  18 
Liver  in  eclampsia,  382 

of  fetus  at  term,  78 
Lobar      pneumonia     during     pregnancy, 

295 
Lochia,  284 

Locomotion  in  pregnancy,  109 
Lohlein's  measurement  of  pelvis,  449 
Lordosis,  486 
Lower  uterine  segment   at  beginning   of 

puerperium,  249 
canalization   of,  during  labor,  1 81, 

1S3 
in  pregnancy,  98 
Lungs  in  eclampsia,  383 

of  fetus  at  term,  78 
Lutein  cells,  18 
Lying-in  chamber,  224 

Macdonald's  (Angus)  theorj- of  eclamp- 
sia, 386 
Malacia  during  pregnancy,  299 
Malacosteon,  476 
Malaria  during  pregnancy,  304 
Male  pronucleus,  21 
Mastitis,  618 

Maternal  endothelium,  57 
Mauriceau    grasp    in   pelvic   presentation, 

514 
Measles  during  pregnancy,  305 
Meigs'  craniotomy  forceps,  735 
Melccna  neonatorum,  630 
Membranes,  pouching  of,  528 

toughness  of,  529 
Menstruation  as  sign  of  pregnancy,  1 13 

in  ectopic  pregnancy,  41 1 


INDEX. 


757 


Menstiuation,  last  date  of,  for  calculating 

date  of  delivery,  131 
Meroblastic  segmentation,  22 
Mesol)last,  25 

extension  of,  25 
Mesoblastic  somites,  26 
Mesothelium,  formation  of,  26 
Metabolism  in  pregnancy,  109 

in  puerperium,  265 
Metritis,  acute,  during  pregnancy,  323 

chronic,  during  pregnancy,  323 

differentiation  of,  from  early  pregnancy, 

125 

Micropyle,  21 

Milk,  human,  analyses  of,  276,  277 
defective  quality  of,  616 
quantity  of,  277 
secretion  of,  276 
variations  in,  278 
leg,  656 
Miscarriage,  357 

Mixed  infection  in  puerperium,  637 
Mole,  formation  of,  404 
Monsters,  537 
double,  538 

relation  of,  to  labor,  538 
Morbus  cseruleus,  83 
Morula,  22 
Moulding  of  head  in  face  delivery,  498 

of  fetus  in  rickety  flat  pelvis,  465 
Mulberry  mass,  22 
Multiple  pregnancy,  133 
Mummification  of  embryo,  406 
Muriform  body,  22 
Murphy  breast  binder,  modified,  616 
Murray's  axis-traction  forceps,  692 

adjustable,  690 
Muscles,  injuries  of,  in  newborn,  623 
Myelitis,  puerperal,  613 
Myoma,    differentiation    of,    from     early 

pregnancy,  126 
Myxoma  diffusum,  350 
fibrosum,  350 

chorii  multiplex,   345.      See  Hydatidi- 
form  degeneration. 

Naegei.e  pelvis,  473 
Nausea  as  sign  of  pregnancy,  II4 
during  pregnancy,  300 


Nephrectomy,  pregnancy  after,  318 
Nephritis  during  pregnancy,  317 
Nerves,  injuries  of,  in  newijorn  infant,  624 
Nervous  signs  of  pregnancy,  115 

system  of  fetus,  86 
Neuritis,  puerperal,  612 
Nevi^born  child,  blood  in,  83 

cleansing  of,  274 

clothing  of,  274 

diseases  of,  621.     See    also  Infant, 
newborn. 

feeding  of,  artificial,  279 
mixed,  279 

incubation  of,  279 
diet  during,  282 
length  of,  283 

management  of,  273 

nursing  of,  274 
Nicholson's  theory  of  eclampsia,  392 
Nipples,  sore,  617 
Node  of  Hensen,  24 
Notochord,  25 
Nucleolus,  17 
Nucleus,  17 

Nurse  during  labor,  224 
Nutrition  of  fetus,  80 

Obesity,  differentiation  of,  from  advanced 

pregnancy,  126 
Obstetrics,  asepsis  and  antisepsis  in,  240 
Occipitodextra  anterior  presentations,  214 
Oligohydramnion,  344 
Omphalorrhagia  neonatorum,  629 
Ophthalmia  of  newborn,  630 
Os  internum,  delimitation  of,  in  labor,  164 

uteri,  dilatation  of,  667 
Osteomalacia  during  pregnancy,  297 
Ovarian  tumor  during  pregnancy,  338 

differentiation      of,    from      advanced 
pregnancy,  1 27 
Ovaries  and  tubes  in  puerperium,  259 
enlarged,  differentiation  of,  from  early 

pregnancy,  126 
lesions  in,  of  puerperal  fever,  644 
of  fetus  at  term,  80 
tumor  of,  417 
in  labor,  438 
Ovariotomy  during  pregnancy,  339 
Ovum,  blighted,  362 


758 


INDEX. 


Ovum,  nature  of  fertilization  of,  21 
of  pregnancy,  17 
place  of  fertilization  of,  20 
relations  between  decidua  and,  45 
ripe,  fate  of,  18 
ripening  of,  19 
segmentation  of,  2 1 

holoblastic,  22 

meroblastic,  22 

Pajot's  manoeuver,  688 
Paralysis  during  pregnancy,  287 
Parametrium,  lesions  in,  of  puerperal  fever> 

644 
Paranucleolus,  17 
Paresis  during  pregnancy,  2S7 
Parovarian  cyst,  differentiation  of,  from  ad- 
vanced pregnancy,  128 
Pelvic  congestion,  605 

floor  projection  in  puerperium,  258 
joints,  rupture  of,  592 
measurements  after  symphysiotomy,  726 
Pelvimeter,  Hirst's,  446 
Pelvimetry,  444 

Pelvis  altered  by  tumors,  disease,  etc.,  486 
anomalies  of,  440 
classification  of,  442 
diagnosis  of,  442 
frequency  of,  441 

in  relation  to  postpartum  uterus,  488 
axis  of  cavity  of,  188 
bony,  184 

contracted,  in  labor,  440 
in  oblique  diameter,  472 
obliquely,  labor  in,  475 
deep,  455 
false,  184 

measurement  of,  189 
fracture  of  bones  of,  593 
funnel-shaped,  454 
generally  compressed,  476 
Hirst's  measurements  of,  450 
in  relation  to  surface  markings,  194 
inclination  of,  187 
justo-major,  453 
Lohlein's  measurement  of,  450 
malacosteon,  476 

labor  in,  478 
male  and  female,  compared,  196 


Pelvis,  masculine,  455 
measurement  of,  189,  444 
external,  444 
internal,  447 
Naegele,  473 
non-rachitic,  455 
obtecta,  482 
outlet  of,  1 86 
physics  of,  in  adult,  194 
pseudomalacosteon  rachitic,  479 
racial  differences  in,  198 
rickety  flat,  457 

changes  in,  459 
diagnosis  of,  461 
shallow,  455 
shape  of  brim  of,  186 
spondylolisthetic,  470 
swellings    of,    in    diagnosis   of    ectopic 

pregnancy,  417 
transversely  contracted,  476 
true,  186 

measurement  of,  in  brim,  190 
in  cavity,  193 
in  outlet,  193 
Pemphigus  in  newborn,  631 
Peptonuria  during  pregnancy,  310 
Perforator,  Simpson's,  737 

Smellies',  734 
Perineal  body  in  puerperium,  258 
Perineum,  care  of,  in  labor,  230 

lacerations  of,  586 
Peritoneum,  lesions  of,  in  puerperal  infec- 
tion, 644 
Peritonitis  from  ectopic  pregnancy,  414 
Peri  vitelline  space,  17 
Perspiration  in  puerperium,  266 
Peters'    (Hubert)   view    of   origin    of  de- 
cidua reflexa,  36 
Phlegmasia  alba  dolens,  656 
Phthisis    pulmonalis     during    pregnancy, 

296 
Pica  during  pregnancy,  299 
Pigmentation  as  sign  of  pregnancy,  1 17 

diirmg  pregnancy,  319 
Placenta,  350 
adherent,  574 

as  protection  against  fetal  poisoning,  87 
calcareous  deposits  on,  350 
causes  of  separation  of,  557 


INDEX. 


759 


Placenta,  changes  in,  effect  of,  on  fetus,  88 
consistence,  weight,  appearance  of,  62 
Crede's  method  of  expelling,  237 
cysts  of,  353 
delivery  of,  155 
edema  of,  350 
expulsion  of,  223-235 
fatty  degeneration  of,  352 
fenestrata,  62-350 
fibrous  degeneration  of,  351 
functions  of,  as  regards  fetus,  86 
growth  of,  after  fetal  death,  407 
in  eclampsia,  384 
inflammation  of,  352 
marginata,  66-354 
praevia,  539 

and     ablatio     placentae,    differential 
points  of,  561 

Csesarean  section  for,  722 

etiology  of,  541 

prognosis  of,  55° 

source  of  bleeding  in,  547 

symptoms  of,  548 

treatment  of,  551 

varieties  of,  540 
premature  detachment  of,  556 
relation  of,  106 

of  umbilical  cord  to,  71 
retained,  571 

retention  of  portions  of,  603 
separation  of,  219 
shed,  61 

size  and  shape  of,  61 
spuria,  61,  350 
succenturiata,  61,  350,  547 
syphilis  of,  352 
transmittal  of  diseases  through,  to  fetus, 

87 
truffe,  67 

tuberculosis  of,  353 
tumors  of,  353 
Placental  apoplexies,  353 
infarcts,  66,  353 
classification  of,  66 
non-fibrinous,  68 
red,  66 

significance  of,  67 
Placentation,  30 
Plasm,  egg,  17 


Pleuriey  during  pregnancy,  296 
Pneumococcus  in  puerperal  infection,  636 
Pneumonia,  lobar,  during  pregnancy,  295 
Polar  body,  first.  19 

second,  19 
Polarity,  law  of,  184 
Polygalactia,  614 

Polyhydramnios,  340.     See  Hydi'amnion. 
Polypus,  fibrinous,  604 
Polyuria  during  pregnancy,  310 
Porro-Cassarean  section,  711 
Porro's  operation,  718 
Postpartum  hemorrhage,  565 
Prague  grasp  in  pelvic  presentation,  513 
Pregnancy,  17 

accidental  hemorrhage  in,  556 
symptoms  of,  559 

acute  metritis  during,  323 
yellow  atrophy  during,  299 

after  Csesarean  section,  718 

after  nephrectomy,  318 

albuminuria  during,  312 

ampullar,  399 

anatomy  of,  1 7 

anomalous  varieties  of,  405 

anteversion  of  uterus  during,  332 

appendicitis  during,  336 

arteries  during,  290 

artificial  interruption  of,  659 

asthma  during,  296 

bacteriology  of  vagina  in,  ill 

bathing  during,  141 

blood  during,  107,  290 

bronchitis  during,  295 

carcinoma  of  rectum  during,  337 
uteri  during,  327 

cardiac  affections  during,  292 
treatment  of,  294 

care  of  breasts  during,  141 
of  genitalia  during,  14I 

caries  of  teeth  during,  298 

catalepsy  during,  289 

cervical  polypi  during,  328 

cervix  in,  97 

changes  in  maternal  system  in,  90 
uterus  in,  90-107 

cholera  during,  303 

chronic  endometritis  during,  323 
metritis  during,  323 


760 


INDEX. 


Pregnancy,  circulatory  system  in,  107 
clothing  during,  140 
constipation  during,  139,  299 
cornual,  406 
corpus  luteum  of,  18 
cough  during,  295 
cystitis  during,  310 
diabetes  insipidus  during,  310 

mellitus  during,  311 
diagnosis  of,  1 1 3 

differential,  125 
diarrhea  during,  299 
diastasis  of  recti  abdominis  muscles  in, 

593 
diet  in,  138 
digestion  in,  109 
duration  of,  129 
dyspnea  during,  295 
ectopic,  397 

abdominal  enlargement  in,  412 

affections  of  digestive  tract  in,  414 

amnion  in,  410 

and  uterine,  concurrent,  407 

at  full  time,  413 

changes  in,  after  fetal  death,  415 
in  breasts  in,  41 1 
in  musculature  of  tube  in,  407 
in  tubal  mucosa  in,  407 

chorion  in,  410 

classification  of,  398 

colicky  pains  in,  41 1 

decidua  reflexa  in,  409 
serotina  in,  408 

diagnosis  of,  415 

discharges  of  uterine  decidua  in,  41 1 

etiology  of,  397 

fetal  movements  in,  412 

hemorrhage  in,  414 

infection  in,  414 

maternal  souffle  in,  412 

menstruation  in,  41 1 

pain  in,  414 

peritonitis  from,  414 

plural,  407 

pressure  effects  in,  413 

relations   in,  between  ovum  and  de- 
cidua, 409 

repeated,  407 

rupture  of  sac  in,  414 


Pregnancy,  ectopic,  signs  of,  410 
complications  in,  413 
treatment  of,  418 
uterine  changes  in,  412 
vaginal  changes  in,  412 
edema  during,  291 

of  vulva  during,  321 
effect  on,  of  operations  for  retroversion, 

337 
emphysema  during,  296 
endocarditis  during,  292 
epilepsy  during,  287 
erysipelas  during,  306 
exercise  during,  140 
exophthalmic  goiter  during,  289 
Fallopian  tubes  in,  105 
false,  138 

female  elements  of,  17 
fibromyoma  uteri  during,  324 
formation  of  corpus  luteum  in,  180 
gingivitis  during,  299 
glandular  changes  in,  ill 
glycosuria  during,  31 1 
haematoma  vulvae  during,  320 
heart  in,  108,  291 
Hegar's  sign  of,  124 
hematuria  during,  310 
hemoptysis  during,  296 
hemorrhage   from   genital   tract   during, 

323 
hepatic  toxemia  during,  299 
hernia  during,  333 
herpes  during,  319 
hydrorrhea  during,  322 
hygiene  of,  138 

hypertrophy  of  vaginal  wall  during,  321 
hysteria  during,  289 
impetigo  herpetiformis  during,  319 
in  old  primiparae,  430 
incarceration  of  uterus  during,  329 
incontinence  of  urine  during,  310 
inflammation   of  external  genitals  dur- 
ing, 320 
of  uterus  during,  323 
influence    of   cerebrospinal    nerves   on, 

175 
of  hydramnion  on,  343 
influenza  during,  303 
infundibular,  405 


INDEX. 


761 


Pregnancy,  insanity  during,  286 
interstitial,  404 

treatment  of,  41S 
intestinal  obstruction  during,  337 
intraperitoneal  inflammation  during,  335 
jaundice  during,  299 
kidneys  during,  31 1 
kyphosis  in,  483 
lateral    displacement   of  uterus   during, 

333 
lobar  pneumonia  during,  295 
locomotion  in,  109 
loosening  of  finger-nails  during,  319 
lower  uterine  segment  in,  98 
malacia  during,  299 
malaria  during,  304 
male  elements  of,  19 
management  of,  138 
measles  during,  305 
metabolism  in,  I09 
multiple,  133 

in  relation  to  labor,  533 
nausea  during,  300 
nephritis  during,  317 
obstetric  examination  during,  142 
osteomalacia  during,  297 
ovarian,  405 

tumor  during,  338 
ovariotomy  during,  339 
ovum  of,  17 

structure  of,  17 
paralysis  during,  287 
pelvic  floor  in,  102 

peritoneum  in,  103 
peptonuria  during,  310 
phthisis  pulmonalis  during,  296 
physiology  of,  17 
pica  during,  299 
pigmentation  during,  319 
pleurisy  during,  296 
polyuria  during,  310 
prolapsus  uteri  during,  328 
protracted,  130 
pruritus  during,  319 
ptyalism  during,  298 
pyelonephritis  during,  318 
pyrosis  during,  299 
reflex  and  electric  excitability  in,  no 
relation  of  placenta  in,  106 


Pregnancy,  respiration  in,  109 
rest  during,  140 

results  of  vaginal  fixation  during,  338 
retention  of  urine  during,  310 
retroversion     and    retroflexion    during, 

329 
rheumatic  fever  during,  306 
rupture  of  uterus  during,  334 
sacculation  of  uterus  during,  333 
scarlatina  during,  304 
septicemia  during,  306 
shock  during,  289 
signs  of,  113 
abdominal,   I17 
consistence,  120 
fetal  heart,  121 

shock,  123 
funic  souffle,  123 
pigmentation,  1 17 
separation  of  recti,  118 
size  and  shape,  118 
striae,  117 
uterine  souffle,  122 
areolar,  116 
ballottement,  125 
gastric,  114 
mammary,  116 
value  of,  117 
menstrual,  1 13 
nervous,  1 15 
quickening,  115 
uterine,  123 
vaginal,  125 
venous,  116 
skin  in,  109 
small-pox  during,  305 
sneezing  during,  295 
spleen  during,  289 
spondylolisthesis  in,  472 
spurious,  differentiation  of,  from  ectopic 

pregnancy,  418 
syphilis  in,  307 

treatment  of,  309 
temperature  in,  109 
tetany  during,  288 
thyroid  gland  during,  289 
toxemia  of,  284-316 
treatment  of  morning  sickness  in,  139 
tuberculosis  during,  306 


762 


INDEX. 


Pregnancy,  tuberculosis  of  bones  in,  297 
tubo-abdominal,  405 
tubo-ovarian,  405 
tubo-peritoneal,  401 
twin,  133-533 

course  and  complications  of,  134 

diagnosis  of,  136 
typhoid  fever  during,  303 
typhus  fever  during,  304 
upper  uterine  segment  in,  98 
urinalysis  during,  141 
urinary  system  in,  1 10 
urine  in,  388 
uterine,  416 
varices  during,  320 
veins  during,  290 
vomiting  during,  300 

pernicious,  300 
vulvar  abscess  during,  320 

cyst  during,  320 
Premature    labor,  357,  663.       See    also 

Labor,  pre??iattcre. 
Presentation,  brow,  501 
face,  495 

Baudelocque's  method  in,  500 

forceps  in,  500 

Humphrey's  method  in,  500 

labor  in,  497 

moulding  of  head  in  delivery  of.  498 

Schatz'  method  in,  499 

to  pubes,  473 
mento-anterior,  497 
mentoposterior,  498 
occipitolseva  anterior,  208 
occipitoposterior,  492 

abnormal,  493 
pelvic,  503 

in  flat  pelvis,  466 
persistent  occipitoposterior,  493 
transverse,  515 

diagnosis  of,  517 

spontaneous  version  in,  518 
vertex,  208 

diagnosis  of,  206 
Primary  caput,  215 
Primitive  groove,  23 
streak,  23 

head-process  of,  24 
Prochorion,  22 


Prolapsus  funis,  529 

uteri  during  pregnancy,  328 
treatment  of,  329 
in  labor,  429 
Pronucleus,  female,  19 

male,  21 
Protoplasm,  clear,  17 

yolk,  17 
Pruritus  during  pregnancy,  319 

vulvae,  319 
Pseudocyesis,  138 

Pseudomalacosteon  rachitic  pelvis,  479 
Ptyalism  during  pregnancy,  298 
Puerperal  infection,  604,  631 

bacillus  aerogenes  capsulatus  in,  636 

diphtheriae  in,  635 
by  gas-producing  organisms,  645 
causes  of,  637 
circulatory  changes  in,  644 
colon  bacillus  in,  635 
diagnosis  of,  650 
favoring  conditions,  639 
frequency  of,  640 
gonococcus  in,  635 
lesions  of,  in  cervix  uteri,  642 
in  intestines,  645 
in  nervous  system,  645 
in  parametrium,  644 
in  peritoneum,  644 
in  respiratory  tract,  645 
in  tube  and  ovary,  644 
in  urinary  tract,  645 
in  uterus,  642 
in  vagina,  641 
in  vulva,  641 
pathologic  anatomy  of,  641 
pneumococcus  in,  636 
prognosis  of,  649 
staphylococcus  in,  634 
streptococcus  pyogenes  in,  633 
symptoms  of,  646 
tetanus  bacillus  in,  636 
treatment  of,  curative,  652 
prophylactic,  652 
rashes,  610 

state,    management    of,    lying-in    room, 
270 
urination,  271 
Puerperium,  248,  601 


INDEX. 


763 


Puerperium,  abdominal  wall  in,  259 
affections  of  nerves  in,  612 
after-pains  in,  268 
alimentary  tract  in,  265 
anatomy  of,  248 
autoinfection  in,  638 
bladder  in,  257 
blood  in,  267 
broad  ligaments  in,  258 
changes  in  urine  in,  610 
cystitis  in,  61 1 

defective  milk  secretion  in,  614 
elevation  of  temperature  in,  610 
galactorrhea  in,  614 
gangrene  in,  614 
general  condition  in,  268 
hetero-infection  in,  637 
incontinence  of  urine  in,  611 
insanity  in,  613 
involution  of  uterus  in,  260 
lochia  in,  264 
management  of,  270 

bowels,  271 

dietetic,  272 

douching,  272 

genitalia,  272 
metabolism  in,  265 
mixed  infection  in,  637 
myelitis  in,  613 
neuritis  in,  612 
ovaries  and  tubes  in,  259 
pelvic  floor  projection  in,  258 
perineal  body  in,  258 
perspiration  in,  266 
phlegmasia  alba  dolens  in,  656 
physiology  of,  248 
polygalactia  in,  614 
pulse  in,  267 
renal  function  in,  269 
respiration  in,  266 
retention  of  urine  in,  61 1 
suppression  of  urine  in,  611 
temperature  in,  267 
tetanus  in,  613 
tetany  in,  614 
urination  in,  266 
uterus  at  beginning  of,  248 
vagina  in,  25 8 
Pulse  in  puerperium,  267 


Pyelonephritis  during  pregnancy,  318 
Pyrosis  during  pregnancy,  299 

Quadruplets,  136 

Quickening  as  sign  of  pregnancy,  115 

Quintuplets,  136 

Rauber's  cells,  22 

Receptive  prominence,  21 

Recti,  separation  of,  as  sign  of  pregnancy, 

118 
Rectum,  cancer  of,  in  labor,  437 

carcinoma  of,  during  pregnancy,  337 
distended,  in  labor,  437 
of  fetus  at  term,  79 
Renal  function  in  puerperium,  269 

of  fetus,  85 
Respiration  in  pregnancy,  109 
in  puerperium,  266 
of  fetus,  81 
Restitution  of  head  in  labor,  212 
Retention  of  urine  during  pregnancy,  310 
Retraction  after  expulsion  of  fetus,  218 

ring,  178 
Retroversion  and  retroflexion  during  preg- 
nancy, 329 
results  of,  329 
symptoms  of,  330 
treatment  of,  331 
effect  of  operation  for,  on  pregnancy,  337 
Reynold's   traction  hooks   applied  to  for- 
ceps, 685 
Rheumatic  fever  during  pregnancy,  306 
Ries'  theory  of  eclampsia,  387 
Ritter's  disease  of  newborn,  631 
Rotation  in  labor,  external,  212 

internal,  210 
Rupture  of  air-passage,  595 
of  cervix,  583 
of  pelvic  joints,  592 
of  perineum,  586 
of  sacro-iliac  joints,  593 
of  uterus,  575 

Sacciform  uterus,  334 
Sacculation  in  labor,  429 

of  pregnant  uterus,  333 

of  uterus,  416 
Sacro-iliac  joints,  rupture  of,  593 


764 


INDEX. 


Sanger's  measurements  of  puerperal  uter- 
ine muscle,  260 
Sapremia,  636 

Scarlatina  during  pregnancy,  304 
Schatz's  method  in  face  presentations,  499 
Schultze's  method  of  artificial  respiration, 

626 
Sclerema  of  newborn,  631 
Scoliosis,  484 

in  labor,  485 
Second  polar  body,  19 
Secondary  caput,  215 
Segmentation  cavity,  22 

nucleus,  21 

of  ovum,  21 
holoblastic,  22 
meroblastic,  22 
Sepsis  neonatorum,  62S 
Septicemia,  acute  general,  645 

during  pregnancy,  306 
Serosa,  formation  of,  27 
Shed  placenta,  61 
Shock  during  pregnancy,  289 
Show,  149 
Simpson's  basilyst,  739 

forceps,  684 

perforator,  737 
Skin  in  pregnancy,  109 
Skull,  indentations  of,  in  newborn,  622 
Small-pox  during  pregnancy,  305 
Smellie  grasp  in  pelvic  presentation,  512 

perforator,  734 
Smellie-Veit  grasp  in  pelvic  presentation, 

Sneezing  during  pregnancy,  295 
Somatopleure,  formation  of,  26 
Somites,  mesoblastic,  26 
Souffle,  maternal,  in    ectopic    pregnancy^ 

412 
Spermatozoa,  19 

motility  of,  20 

vitality  of,  20 
Spinal  column,  division  of,  in  fetus,  745 
Splanchnopleure,  formation  of,  26 
Spleen  during  pregnancy,  289 
Spondylolisthesis,  470 

in  labor,  472 

in  pregnancy,  472 

treatment  of,  472 


Spontaneous  evolution   in  transverse  pre- 
sentation, 518 
version  in  transverse  presentation,  518 
Staphylococcus  in  puerperal  infection,  634 
Stomach  of  fetus  at  term,  78 
Stratum  granulosum,  17 
Streptococcus  pyogenes  in  puerperal  infec. 

tion,  633 
Strije  as  sign  of  pregnancy,  117 
Stumpf's  theory  of  eclampsia,  387 
Subinvolution,  601 
Superfecundation,  136 
Superfetation,  137 
Superin volution,  602 
Suprarenal  bodies  of  fetus  at  term,  79 
Sylvester's  method  of  artificial  respiration, 

627 
Symphysiotomy,  Ayer's  method  of,  729 
complicating  conditions  in,  731 
effect  of,  on  pelvic  measurements,  726 
open  method  of,  728 
scope  of,  724 

subcutaneous  method  of,  729 
Symphysotomy,  724.     See  also  Symphysi- 

otoviy. 
Syphilis  in  pregnancy,  307 
treatment  of,  309 
maternal  and  paternal,  effect  of,  on  fetus, 
308 
effect  of,  on  fetus,  307 
of  placenta,  352 
paternal,  effect  of,  on  fetus,  307 
transmission  of,  to  fetus,  307 

Tarnier's  axis-traction  forceps,  681 

basiotribe,  739 
Teeth  during  pregnancy,  298 
Temperature  in  pregnancy,  109 

in  puerperium,  267 
Tetanus   bacillus    in    puerperal   infection, 
636 

during  pregnancy,  288 

of  newborn,  630 

puerperal,  613 
Tetany,  pregnancy  during,  288 

puerperal,  614 
Theca  folliculi,  18 
Thorax  of  fetus,  enlarged,  525 
Thrombosis  after  labor,  602 


INDEX. 


765 


Thymus  gland  of  fetus  at  term,  78 
Thyroid  gland  during  pregnancy,  289 

influence  of,  in  eclampsia,  392 
Toxemia,  hepatic,  during  pregnancy,  299 

of  pregnancy,  284,  316 
Traube's  theory  of  eclampsia,  385 
Trephine,  Braun's,  734 
Trilaminar  blastoderm,  24 
Triplets,  136,  537 
True  corpus  luteum,  18 
Tuberculosis  during  pregnancy,  306 
of  bones  during  pregnancy,  297 
of  placenta,  353 
Tuberose  subchorionic  hematoma    of  de- 

cidua,  362 
Tubes  and  ovaries  in  puerperium,  259 
Tumor  of  ovary,  417 

differentiation     of,     from     advanced 

pregnancy,    127 
during  pregnancy,  338 

treatment  of,  339 
in  labor,  438 
fibromyomatous,  differentiation  of,  from 

ectopic  pregnancy,  417 
of  fetus,  527 
of  placenta,  353 
uterine,  differentiation  of,  from  advanced 

pregnancy,  127 
of  uterus  in  labor,  430 
of  vulva  and  vagina  in  labor,  437 
vulvar,  during  pregnancy,  320 
Tunica  externa,  18 
fibrosa,  18 
interna,    18 
propria,   18 
Twin  labors,  533 
Twins,  133 
binovular,  133 
course  and  complications  of  pregnancy 

with,  134 
disposition  of,  136 
uniovular,  134 
Typhoid  fever  during  pregnancy,  303 

transmission  of,  from  mother  to  fetus, 
304 
Typhus  fever  during  pregnancy,  304 

Umkilicai.  cord,  355 

changes  in  vessels  of,  356 


Umbilical    cord,  construction  and   devel- 
opment of,  69 
convolution  of,  355 
hernia  in,  356 
insertion  of,  63 

velamentous,  63 
knots  in,  356 
false,  356 
true,  356 
ligature  of,  233 
prolapse  of,  529 
relation  of,  to  fetus,  7 1 

to  placenta,  71 
rupture  of,  529 
short,  522 
swellings  of,  356 
torsion  of,  355 

velamentous  insertion  of,  355 
hernia  in  newborn,  629 
Umbilicus  of  fetus  at  term,  79 

septic  infection  of,  in  newborn,  628 
Upper  uterine   segment   at  beginning    of 
puerperium,  248 
in  pregnancy,  98 
Ureters,  compression  of,  as  cause  of  albu- 
minuria of  pregnancy,  314 
Urethra  during  labor,  170 

of  fetus  at  term,  79 
Urinalysis  during  pregnancy,  141 
Urinaiy  system  in  pregnancy,  no 
Urination  in  puerperium,  266 
Urine,  changes  in,  in  puerperium,  610 
in  eclampsia,  350,  388—393 
incontinence  of,  during  pregnancy,  310 

in  puerperium,  61 1 
retention  of,  during  pregnancy,  310 

in  puerperium,  61 1 
suppression  of,  in  puerperium,  61 1 
toxicity  of,  in  pregnancy,  388 
Uterine  contractions  in  excised  uterus,  175 
hydatid,   345.     See    Hydatidiform    de- 
generation. 
signs  of  pregnancy,  123 
souffle  as  sign  of  pregnancy,  122 
tumors,    differentiation     of,     from    ad- 
vanced pregnancy,  127 
Uterus  after  first  day  of  puerperium,  252 
anteversion  of,  during  pregnancy,  332 
at  beginning  of  puerperium,  248 


766 


INDEX. 


Uterus,  carcinoma  of,  during  pregnancy, 

327 

changes  in,  during  pregnancy,  90-107 
in  ectopic  pregnancy,  412 
in  mucosa  of,  in  puerperium,  262 
in  vessels  of,  in  puerperium,  262 

contractions  of,  in  labor,  175 

displacements  of,  604 

during  labor,  175 

fibromyoma  of,  during  pregnancy,  324 

form  and  size  of,  during  labor,  156 

hardening  of,  in  labor,  176 

in  eclampsia,  383 

in  first  and  second  stages  of  labor,  156 

in  third  stage  of  labor,  215 

incarceration  of,  during  pregnancy,  329 

incision  of,  in  Carsarean  section,  716 

inflammation  of,  during  pregnancy,  323 

influence  of  cerebrospinal  nerve  on,  175 
of  fertilization  on  mucosa  of,  30 

inversion  of,  588 

lateral    displacement    of,  during    preg- 
nancy, III 

lesions  of  puerperal  infection  in,  642 

macroscopic    appearance    of,    in    early 
puerperium,  254 

malformations  of,  428 

mucosa   of,  changes  in,  in  pregnancy, 

30 

in  nullipara:,  30 
obliquity  of,  in  labor,  428 
of  fetus  at  term,  79 
pregnant,  blood-vessels  of,  I02 

divisions  of  wall  of,  96 

measurements  of,  93 

musculature  of,  loi 

position  of,  93 

relationships  of,  105 

retroversion  of,  416 

shape  and  size  of,  90 

statistics    of  operations   for  retrover- 
sion of,  337 

volume  of,  96 

vs^eight  of,  96 
premature  emptying  of,  357 
prolapse  of,  during  pregnancy,  328 

in  labor,  429 
relation  of,  to  extra-uterine  tissues  and 
pelvis  in  early  puerperium,  256 


Uterus,  relaxation  of,  604 
retraction  of,  605 

after  expulsion  of  fetus,  215 

nature  of,  178 
retroversion  and  retroflexion  of,  during 

pregnancy,  329 
rupture  of,  575 

diagnosis  of,  581 

during  pregnancy,  334 

etiology  of,  576 

frequency  of,  577 

prognosis  of,  581 

symptoms  of,  579 

treatment  of,  582 
sacciform,  334 
sacculation  of,  416 

during  pregnancy,  333 
shape  of,  after  expulsion  of  fetus,  218 
subinvolution  of,  601 
superinvolution  of,  602 
supravaginal  amputation  of,  718 
suture  of,  in  Csesarean  section,  717 
upward  traction  of  retracting  and  con- 
tracting portions  of,  184 

Vaccination    during    pregnancy,    effect 

of,  on  fetus,  305 
Vagina  after  expulsion  of  fetus,  219 

changes  in,  in  ectopic  pregnancy,  412 
in  puerperal  infection,  641 

cystic  swellings  of,  in  labor,  437 

edema  of,  in  labor,  436 

hematoma  of,  in  labor,  436 

in  labor,  168 

in  pregnancy,  bacteriology  of,  III 

in  puerperium,  258 

lacerations  of,  584 

of  fetus  at  term,  80 

rigidity  of,  in  labor,  435 

tumors  of,  in  labor,  437 

varicose  veins  of,  in  labor,  436 

wounds  in,  605 
Vaginal  fixation,  results  of,  338 

signs  of  pregnancy,  125 

wall,  hypertrophy  of,  during  pregnancy, 
321 
Varices  during  pregnancy,  320 
Varicose  veins  of  vulva  and  vagina  in  labor, 
436 


INDEX. 


767 


Veins  as  signs  of  pregnancy,  1 16 

during  pregnancy,  290 
Version,  669 

bipolar,  676 

combined  internal  and  external,  676 

difficulties  in,  675 

external,  669 

internal,  670 
dangers  in,  676 

pelvic,  671 

podalic,  671 

spontaneous,  in  transverse  presentation, 
518 
Vesicular  mole,  345.      See  Hydatidiform 

degeneration. 
Vitelline  duct,  formation  of,  27 
Vomiting  as  sign  of  pregnancy,  1 14 

during  pregnancy,  300 
pernicious,  300 
Vulva,  abscess  of,  in  labor,  436 

changes  in,  in  puerperal  infection,  641 

cystic  swellings  of,  in  labor,  437 


Vulva,  edema  of,  during  pregnancy,  321 
in  labor,  436 

hematoma  of,  in  labor,  436 

rigidity  of,  in  labor,  435 

tumors  of,  in  labor,  437 

varicose  veins  of,  in  labor,  436 

wounds  in,  605 
Vulvar  abscess  during  pregnancy,  320 

cyst  during  pregnancy,  320 

tumors  during  pregnancy,  320 

Wai.cher  position,  468 
Wet-nursing,  278 
Whartonian  jelly,  70 
White  swelling,  656 

Wigand-Martin  method  in  pelvic  presenta- 
tions, 514 

Yolk  protoplasm,  17 

Zellknoten,  65 
Zona  pellucida,  17 


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original  German.  In  view  of  these  facts,  Messrs.  W.  B.  Saunders  & 
Company  have  arranged  with  the  publishers  of  the  German  edition 
to  issue  at  once  an  authorized  American  edition  of  this  great  Practice  of  Medicine. 

For  the  present  a  set  of  ten  volumes,  selected  with  especial  thought  of  the  needs  of  the 
practising  physician,  will  be  published.     These  volumes  will  con- 


BEST  IN 
EXISTENCE 


FOR  THE 
PRACTITIONER 


tain  the  real   essence  of  the   entire   work,  and  the  purchaser  will 
therefore  obtain,  at  less  than  half  the  cost,  the  cream  of  the  orig- 
inal.    Later  the  special  and  more   strictly  scientific  volumes  will 
be  offered  from  time  to  time. 
The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both  English  and 
German,  and  each  volume  will  be  edited  by  a  prominent  specialist.     It  will  thus  be  brought 
thoroughly  up   to  date,  and   the   American  edition  will  be  more  than  a  mere  translation  ;  for, 
in  addition  to  the  rriatter  contained  in  the  original,  it  will  represent 


PROMINENT 
SPECIALISTS 


the  very  latest  views  of  the  leading  American  and  English  special- 
ists in  the  various  departments  of  Internal  Medicine.  Moreover, 
as  each  volume  will  be  revised  to  the  date  of  its  publication  by  the 
eminent  editor,  the  objection  that  has  heretofore  existed  to  treatises 
published  in  a  number  of  volumes  will  be  obviated,  since  the  subscriber  will  receive  the  com- 
pleted work  while  the  earlier  volumes  are  still  fresh.  The  American  publication  of  the  entire 
work  is  under  the  editorial  supervision  of  Dr.  ALFRED  STENGEL,  who  has  selected  the  subjects 
for  the  American  Edition,  and  has  chosen  the  editors  of  the  different  volumes. 

The  usual  method  of  publishers  when  issuing  a  publication  of 
this  kind  has  been  to  require  physicians  to  take  the  entire  work. 
This  seems  to  us  in  many  cases  to  be  undesirable.  Therefore,  in 
purchasing  this  Practice  physicians  will  be  given  the  opportunity 
of  subscribing  for  it  in  entirety ;  but  any  single  volume  or  any 
number  of  volumes,  each  complete  in  itself,  may  be  obtained  by  those  who  do  not  desire  the 
complete  series.  This  latter  method  offers  to  the  purchaser  many  advantages  which  will  be 
appreciated  by  those  who  do  not  care  to  subscribe  for  the  entire  work  at  one  time. 

SEE  NEXT  TWO  PAGES  FOR  LIST 


VOLUMES  SOLD 
SEPARATELY 


PRACTICE    OF  MEDICINE. 


AMERICAN   EDITION 

NOTHNAGEL'S  PRACTICE 

VOLUMES    NOW   READY 


Typhoid  and  Typhus  Fevers 

By  Dr.  H.  Curschmaxn,  Professor  of  Medicine  in  Leipsic.  The  entire 
volume  edited,  with  additions,  by  William  Osler,  M.  D.,  F.  R.  C.  P., 
Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  Univer- 
sity, Baltimore.  Octavo,  646  pages,  illustrated.  Cloth,  $5.00  net  ;  Half 
Morocco,  $6.00  net. 

"Under  the  editorial  supervision  of  Dr.  Osier,  the  original  German  work,  excellent 
though  it  is,  has  been  much  improved,  greatly  enlarged,  and  enhanced  in  value,  espe- 
cially to  American  readers.  .  .  .  The  monograph  on  typhoid  fever  is  the  best  exponent 
of  the  knowledge  that  we  have  in  regard  to  this  disease  that  is  to  be  had  in  any  lan- 
guage."— Journal  of  the  American  Medical  Association. 

Smallpox  (including  Vaccination),  Varicella,  Cholera  Asiatica, 
Cholera  Nostras,  Erysipelas,  Erysipeloid,  Pertussis,  and 
Hay  Fever 

By  Dr.  H.  Immermann,  of  P3asle  ;  Dr.  Th.  von  Jurgensen,  of  Tiibin- 
gen  ;  Dr.  C.  Liebermeister,  of  Tiibingen  ;  Dr.  H.  Lenhartz,  of  Ham- 
burg ;  and  Dr.  G.  Sticker,  of  Giessen.  The  entire  volume  edited,  with 
additions,  by  Sir  J.  W.  Moore,  M.  D.,  F.  R.  C.  P.  I.,  Professor  of  Prac- 
tice, Royal  College  of  Surgeons,  Ireland.  Octavo,  682  pages,  illustrated. 
Cloth,  $5.00  net  ;   Half  Morocco,  $6.00  net. 

"  Dr.  Immermann's  vindication  of  vaccination  in  the  prophylaxis  of  smallpox  will  be 
read  with  peculiar  interest  at  the  present  time,  since  it  is  probably  the  most  complete 
and  unassailable  indictment  of  the  propaganda  of  antivaccination  fanatics  which  has  ever 
been  published." — The  London  Lancet. 

Diphtheria,  Measles,  Scarlet  Fever,  and  Rotheln 

By  William  P.  Northrup,  M.  D.,  of  New  York,  and  Dr.  Th.  von 
Jurgensen,  of  Tiibingen.  The  entire  volume  edited,  with  additions,  by 
William  P.  Northrup,  M.  D.,  Professor  of  Pediatrics,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  Octavo,  672  pages,  illus- 
trated, including  24  full-page  plates,  3  in  colors.  Cloth,  $5.00  net  ;  Half 
Morocco,  $6.00  net. 

"  The  author  is  to  be  congratulated  on  the  exhaustive  and  practical  manner  in  which 
he  presents  the  subject.  .  .  .  The  articles  on  measles,  scarlet  fever,  and  German  measles 
are  exhaustive  treatises,  with  numerous  additions  by  the  "American  editor." — Journal 
of  the  American  Medical  Association. 

Diseases  of  the  Bronchi,  Diseases  of  the  Pleura,  and  In- 
flammations of    the  Lungs 

By  Dr.  F.  A.  Hoffmann,  of  Leipsic  ;  Dr.  O.  Rosenbach,  of  Berlin  ;  and 
Dr.  F.  Aufrecht,  of  Magdeburg.  The  entire  volume  edited,  with  additions, 
by  John  H.  Mus.ser,  M.  D.,  Professor  of  Clinical  Medicine,  University  of 
Pennsylvania.  Octavo,  1029  pages,  illustrated,  including  7  full-page  colored 
lithographic  plates.     Cloth,  ^5.00  net ;  Half  Morocco,  $6.00  net. 

"  These  monographs  in  the  original  hold  an  enviable  place  in  German  medical  literature, 
each  one  being  exhaustive,  complete,  authoritative,  and  written  by  men  specially  fitted  for 
the  work.  But  the  American  otiition  is  not  only  a  reproduction  in  English,  it  is  all  of  this 
and  more;  for  the  American  editor  has  added  much  of  value  not  included  in  the  original, 
and  he  has  brought  every  part  thoroughly  up  to  (\z.Xe."— Journal  of  the  American  Medical 
Association. 


SAUJVDERS'    BOOKS   ON 


AMERICAN    EDITION 

NOTHNAGEL'S  PRACTICE 

VOLUMES  NOW  READY  AND  IN  PRESS 


Diseases  of  the  Pancreas,  Suprarenals,  and  Liver 

By  Dr.  L.  Oser,  of  Vienna  ;  Dr.  E.  Neusser,  of  A'ienna,  and  Drs.  H. 
Quincke  and  G.  Hoppe-Seyler,  of  Kiel.  The  entire  volume  edited,  with 
additions,  by  Reginald  H.  Fitz,  A.  M.,  M.  D.,  Hersey  Professor  of  the 
Theory  and  Practice  of  Physic,  Harvard  University  ;  and  Frederick  A. 
Packard,  M.  D.,  Late  Physician  to  the  Pennsylvania  and  to  the  Children's 
Hospitals.  Octavo  of  918  pages,  illustrated.  Cloth,  $5.00  net  ;  Half  Mo- 
rocco, $6.00  net. 

It  has  been  the  aim  of  the  authors  and  editor  of  this  work  to  describe  the  present  con- 
dition of  our  knowledge  on  the  subjects,  to  point  out  where  it  is  deficient,  and  to  stimu- 
late to  new  work.     The  work  will  be  found  practical  in  every  particular. 

Diseases  of  the  Stomach 

By  Dr.  F.  Riegel,  of  Giessen.  Edited,  with  additions,  by  Charles 
G.  Stockton,  M.  D.,  Professor  of  Medicine,  University  of  Buffalo.  Hand- 
some octavo  of  835  pages,  with  29  text-cuts  and  6  full-page  plates.  Cloth, 
$5.00  net  ;  Half  Morocco,  $6.00  net. 

This  work  is  a  complete  exposition  of  the  diseases  of  the  stomach.  Full  consideration 
is  given  to  the  hydrochloric  acid  question,  the  latest  views  being  incorporated  by  the 
editor.     Particular  attention  has  been  given  to  disturbances  of  motility  and  secretion. 

Diseases  of  the  Intestines  and  Peritoneum 

By  Dr.  Hermann  Nothnagel,  of  Vienna.  The  entire  volume  edited, 
with  additions,  by  Humphrey  D.  Rolleston,  M.  D.,  F.  R.  C.  P.,  Physi- 
cian to  and  Lecturer  on  Pathology  at  St.  George's  Hospital,  London.  Hand- 
some octavo  of  800  pages,  finely  illustrated. 

Influenza,  Dengue,  Malarial  Diseases 

By  Dr.  O.  Leichtenstern,  of  Cologne,  and  Dr.  J.  Mannaberg,  of 
Vienna.  The  entire  volume  edited,  with  additions,  by  Ronald  Ross, 
F.  R.  C.  S.,  Eng.,  D.  p.  H.,  F.  R.  S.,  Major,  Indian  Medical  Service,  retired  ; 
Walter  Myers  Lecturer,  Liverpool  School  of  Tropical  Medicine,  Liverpool. 
Handsome  octavo  of  700  pages,  with  7  full-page  lithographic  plates  in 
colors. 

Anemia,    Leukemia,    Pseudoleukemia,    Hemoglobinemia,    and 
Chlorosis 

By  Dr.  P.  Ehrlich,  of  Frankfort-on-the-Main  ;  Dr.  A.  Lazarus,  of 
Charlottenburg  ;  Dr.  Felix  Pinkus,  of  Berlin  ;  and  Dr.  K.  von  Noorden, 
of  Frankfort-on-the-Main.  The  entire  volume  edited,  with  additions,  by 
Alfred  Stengel,  M.  D.,  Professor  of  Clinical  Medicine,  University  of 
Pennsylvania.  Handsome  octavo  of  750  pages,  with  5  full-page  lithographs 
in  colors. 

Tuberculosis  and  Acute  General  Miliary  Tuberculosis 

By  Dr.  G.  Cornet,  of  Berhn.  Edited,  with  additions,  by  Walter  B. 
James,  M.  D.,  Professor  of  the  Practice  of  Medicine,  Columbia  LJniversity, 
New  York.      Handsome  octavo  of  700  pages. 

EACH  VOLUME  IS  COMPLETE  IN  ITSELF  AND  IS  SOLD  SEPARATELY 


THE  PRACTICE   OF  MEDICINE 


Eichhorst's 
Practice  of  Medicine 

A  Text=Book  of  the  Practice  of  Medicine.  By  Dr.  Hermann  Eich- 
HORST,  Professor  of  Special  Pathology  and  Therapeutics  and  Director 
of  the  Medical  Clinic,  University  of  Zurich.  Translated  and  edited  by 
Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Phila- 
delphia Polyclinic.  Two  octavo  volumes  of  600  pages  each,  with  over 
1 50  illustrations.  Price  per  set :  Cloth,  ^6.00  net ;  Sheep  or  Half 
Morocco,  $7.50  net. 

BY  ONE   OF  THE  GREATEST   OF  GERMAN   CLINICIANS 

This  book  is  a  new  one,  but  on  its  publication  it  sprang  into  immediate 
popularity,  and  is  now  one  of  the  leading  text-books  in  Germany.  It  is  prac- 
tically a  condensed  edition  of  the  author's  great  work  on  Special  Pathology  and 
Therapeutics,  and  it  forms  not  only  an  ideal  text-book  for  students,  but  a  practical 
guide  of  unusual  value  to  practising  physicians. 

Bulletin  of  Johns  Hopkins  Hospital 

"  This  book  is  an  excellent  one  of  its  kind.  Its  completeness,  yet  brevity,  the  clinical 
methods,  the  excellent  paragraphs  on  treatment  and  watering-places,  will  make  it  very  desir- 
able." 


Bridg(e  on  Tuberculosis 

Tuberculosis:  Recast  from  Lectures  Delivered  at  Rush  Medical 
College.  By  Norman  Bridge,  A.  M.,  M.  D.,  Emeritus  Professor  of 
Medicine  in  Rush  Medical  College,  in  affiliation  with  the  University 
of  Chicago.      i2mo  of  302  pages,  illustrated.     Cloth,  ^1.50  net. 

JUST   ISSUED 

In  this  excellent  work  the  practical  side  of  the  care  and  management  of  those 
sick  with  the  various  non-surgical  forms  of  tuberculosis  has  been  concisely  stated. 
Full  consideration  has  been  given  to  prophylaxis,  an  all-important  phase  of  the 
subject  that  has  heretofore  been  much  neglected.  There  are  also  chapters  upon 
the  Bacillus  of  Tuberculosis  ;  on  the  Pathology,  Etiology,  Symptoms,  Physical 
Signs,  Diagnosis,  and  I'rognosis  of  the  disease,  each  treated  in  the  judicious  and 
thorough  manner  to  be  expected  in  a  work  by  such  a  well-known  authority  as  Dr. 
Bridge.     Treatment  is  accorded  unusual  space. 


SAUNDERS'   BOOKS   ON 


Sollmann's  Pharmacology 

Including^  Therapeutics,  Materia  Medica,  Pharmacy, 
Prescription-writing,  Toxicology,  etc. 


A  Text=Book  of  Pharmacology.  By  Torald  Sollmann,  M.  D., 
Assistant  Professor  of  Pharmacology  and  Materia  Medica,  Medical 
Department  of  Western  Reserve  University,  Cleveland,  Ohio.  Hand- 
some octavo  volume  of  894  pages,  fully  illustrated.     Cloth,  $3.75  net. 

A   NEW   WORK— RECENTLY   ISSUED 

This  work  aims  to  furnish  a  scientific  discussion  and  definite  conception  of  the 
action  of  drugs,  as  well  as  their  derivation,  composition,  strength,  and  dose.  The 
author  bases  the  study  of  therapeutics  on  a  systematic  knowledge  of  the  nature 
and  properties  of  drugs,  and  thus  brings  out  forcibly  the  intimate  relation  between 
pharmacology  and  practical  medicine. 

J.  F.  Fotheringhaim,  M.  D. 

Prof,  of  Therapeutics  and  Theo)y  and  Practice  of  Prescribing,  Trinity  Med.  College,  Toronto. 
■'  The  work  certainly  occupies  ground  not  covered  in  so  concise,  useful,  and  scientific  a 
manner  by  any  other  text  I  have  read  on  the  subjects  embraced." 

Butler's   Materia   Medica 

Therapeutics,  and  Pharmacology 

A  Text=Bookof  Materia  Medica,  Therapeutics,  and  Pharmacology. 

By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  of  Materia  Medica  and 
of  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago, 
Octavo,  896  pages,  illustrated.  Cloth,  $4.00  net ;  Sheep  or  Half  Morocco, 
^5.00  net. 

FOURTH    EDITION.  REVISED   AND   ENLARGED 

In  this  new  edition  the  chapters  on  Organo-therapy,  Serum-therapy,  and  cog- 
nate subjects  have  been  enlarged  and  carefully  revised.  An  important  addition 
is  the  chapter  devoted  to  the  newer  theories  of  electrolytic  dissociation  and  its 
relation  to  the  topic  of  pharmacotherapy. 

Medical  Record,  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to  the  com- 
pleteness of  the  text,  and  the  student  or  general  reader  is  given  the  benefit  of  latest  advices 
bearing  upon  the  value  of  drugs  and  remedies  considered." 


THE   PRACTICE    OF  MEDICINE.  13 


Gould    and   Pyle*s 
Curiosities  of  Medicine 


Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould, 
M.  D.,  and  Walter  L.  Pyle,  M.  D.  An  encyclopedic  collection  of 
rare  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an 
exhaustive  research  of  medical  literature  from  its  origin  to  the  present 
day,  abstracted,  classified,  annotated,  and  indexed.  Handsome  octavo 
volume  of  968  pages,  295  engravings,  and  12  full-page  plates. 

Popular  Edition  :  Cloth,  $3.00  net  ;  Sheep  or  Half  Morocco.  $4-00  net. 

As  a  complete  and  authoritative  Book  of  Reference  this  work  will  be  of  value 
not  only  to  members  of  the  medical  profession,  but  to  all  persons  interested  in 
general  scientific,  sociologic,  and  medicolegal  topics  ;  in  fact,  the  absence  of  any 
complete  work  upon  the  subject  makes  this  volume  one  of  the  most  important 
literary  innovations  of  the  day. 

The  Lancet,  London 

"The  book  is  a  monument  of  untiring  energy,  keen  discrimination,  and  erudition.  .  .  . 
We  heartily  recommend  it  to  the  profession." 

Saunders'  Year-Book 


Tiie  American  Year=Book  of  Medicine  and  Surgery.     A  Yearly 

Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all  branches 
of  Medicine  and  Surgery,  drawn  from  journals,  monographs,  and  text- 
books of  the  leading  American  and  foreign  authors  and  investigators. 
Arranged  with  critical  editorial  comments  by  eminent  American  special- 
ists, under  the  editorial  charge  of  George  M.  Gould,  M.  D.  In  two 
volumes — Vol.  I.,  including  General  Medicine ;  Vol.  II.,  General  Stir- 
gery.  Per  volume  :  Cloth,  ^3.00  net;  Half  Morocco,  ^3.75  net.  Sold 
by  Subscription. 

EQUIVALENT  TO   A   POSTGRADUATE   COURSE 

The  Lancet,  London 

"  It  is  much  more  than  a  mere  compilation  of  abstracts,  for,  as  each  section  is  entrusted  to 
experienced  and  able  contributors,  the  reader  has  the  advantage  of  certain  critical  commen- 
taries and  expositions  .  .  proceeding  from  writers  fully  qualified  to  perform  these  tasks." 


14  SAUNDERS'  BOOKS    ON 

Thornton's   Dose-Book 

Dose=Book  and  Manual  of  Prescription=Writing.  By  E.  Q.  Thorn- 
ton, M.  D.,  Assistant  Professor  of  Materia  Medica,  Jefferson  Medical 
College,  Phila.  Post-octavo,  362  pages,  illustrated.  Flexible  Leather, 
$2.00  net. 

Second  Edition,  Revised  and  Enlarged 

In  the  new  edition  of  this  work,  intended  for  the  student  and  practitioner, 
additions  have  been  made  to  the  chapters  on  ' '  Prescription-Writing ' '  and 
"  Incompatibihties,"  and  references  have  been  introduced  in  the  text  to  the 
newer  curative  sera,  organic  extracts,  synthetic  compounds,  and  vegetable  drugs. 
To  the  Appendix,  chapters  upon  Synonyms  and  Poisons  and  their  antidotes 
have  been  added,  thus  increasing  its  value  as  a  book  of  reference. 

C.  H.  Miller.  M.  D.. 

Pi'ofessor  of  Pharmacology,  Northwestern  University  Medical  School,  Chicago. 

"  I  will  be  able  to  make  considerable  use  of  that  part  of  its  contents  relating  to  the  correct 
terminology  as  used  in  prescription-writing,  and  it  will  afford  me  much  pleasure  to  recommend 
the  book  to  my  classes,  who  often  fail  to  find  this  information  in  their  other  text-books." 


American  Text-Book  of 
Applied  Therapeutics 

American  Text=Book  of  Applied  Therapeutics.  Edited  by  James 
C.  Wilson,  M.  D.,  Professor  of  Practice  of  Medicine  and  of  Clinical 
Medicine,  Jefferson  Medical  College,  Philadelphia.  Handsome  imperial 
octavo  volume  of  1326  pages.  Illustrated.  Cloth,  ;^7.00  net;  Sheep 
or  Half  Morocco,  $8.00  net. 

For  Student  and  Practitioner 

Written  for  both  the  student  and  practitioner,  the  aim  of  this  work  is  to 
facilitate  the  application  of  knowledge  to  the  prevention,  cure,  and  alleviation 
of  disease.  The  endeavor  throughout  has  been  to  conform  to  the  title  of  the 
book — "Applied  Therapeutics  " — to  indicate  the  course  of  treatment  to  be  pur- 
sued at  the  bedside,  rather  than  to  name  a  list  of  drugs  that  have  been  used  at 
one  time  or  another.      The  work  will  be  found  accurate  and  trustworthy. 

Buffalo  Medical  Journal 

"  It  is  one  of  the  most  complete  books  of  reference  that  has  been  presented  to  the  profes- 
sion on  medicine  in  a  long  period  of  time ;  and  never  before  have  we  had  one  that  undertook 
to  cover  the  field  in  this  manner." 


PRACTICE,   MATERIA    MEDIC  A,   Etc.  15 

The  American  Pocket  Medical  Dictionary.  Fourth  Edition,  Revised 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  Newman  Dor- 
land,  M.  D.,  Assistant  Obstetrician  to  the  Hospital  of  the  University  of  Pennsylvania. 
Containing  the  pronunciation  and  definition  of  the  principal  words  used  in  medicine 
and  kindred  sciences,  with  64  extensive  tables.  Flexible  leather,  with  gold  edges, 
igl.oo  net;  with  thumb  index,  ^1.25  net. 

"I  can  recommend  it  to  our  students  without  reserve." — ^J.  H.  Holland,  M.  D.,  Dean  of  the 
Jefferson  Medical  College,  Philadelphia. 

Vierordt*S    Medical    Diag^nOSis.      Fourth  Edition,  Revised 

Medical  Diagnosis.  By  Dr  Oswald  Vierordt,  Professor  of  Medicine,  Univer- 
sity of  Heidelberg.  Translated  from  the  fifth  enlarged  German  edition  by  Francis 
H.  Stuart,  A.  M.,  M.  D.  Octavo,  603  pages,  104  wood  cuts.  Cloth,  ^4.00  net; 
Sheep  or  Half  Morocco,  ^5.00  net. 

"  Has  been  recognized  as  a  practical  work  of  the  highest  value.  It  may  be  considered  indispensable 
both  to  students  and  practitioners." — F.  Minot,  M.  D.,  late  Professor  o/  Theory  and  Practice  in 
Harvard  University. 

Cohen   and    Cshner's    Diag[nOSis.      Second  Revised  Edition 

Essentials  of  Diagnosis.  By  S.  Solis-Cohen,  M.  D.,  Senior  Assistant  Professor 
in  Clinical  Medicine,  Jefferson  Medical  College,  Phila.  ;  and  A.  A.  Eshner,  M.  D., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  Post-octavo,  382  pages  ;  55 
illustrations.      Cloth,  ^i. 00  net.     In  Saunders'  Qitestion-Compend  Series. 

"  Concise  in  the  treatment  of  subject,  terse  in  expression  of  fact." — Atnerican  Journal  of  the 
Medical  Sciences. 

Morris*  Materia  Medica  and  Therapeutics.     Fifth  Revised  Edition 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription-Writing. 
By  Henry  Morris,  M.  D.,  late  Demonstrator  of  Therapeutics,  Jefferson  Medical 
College,  Phila.  Post-octavo,  250  pages.  Cloth,  ^i.co  net.  In  Saunders'  Question- 
Co7npend  Series. 

"  Cannot  fail  to  impress  the  mind  and  instinct  in  a  lasting  manner." — Buffalo  Medical  Journal. 

Sayre's    Practice   of   Pharmacy.      Second  Edition,  Revised 

Essentials  of  the  Practice  of  Pharmacy.  By  Lucius  E.  Sayre,  M.  D.,  Pro- 
fessor of  Pharmacy,  University  of  Kansas.  Post-octavo,  200  pages.  Cloth,  ^i. 00  net. 
In  Saunders^  Question- Compend  Series. 

"  The  topics  are  treated  in  a  simple,  practical  manner,  and  the  work  forms  a  very  useful  student's 
manual." — Boston  Medical  and  Surgical  Journal. 

BrOCkway's    Medical    Physics.      Second  Edition,  Revised 

Essentials  of  Medical  Physics.  By  Fred.  J.  Brockway,  M.  D.,  late  Assistant 
Demonstrator  of  Anatomy,  College  of  Physicians  and  Surgeons,  N.  Y.  Post-octavo, 
330  pages  ;  155  fine  illustrations.  Cloth,  ^i.od  net.  In  Saiaiders^  Question- Compend 
Series. 

"  It  contains  all  that  one  need  know  on  the  subject,  is  well  written,  and  is  copiously  illustrated." — 
Medical  Record,  New  York. 

Stoney's  Materia  Medica  for  Nurses 

Materia  Medica  F'>r  Nurses.  By  Emily  A.  M.  Stoney,  Superintendent  of  the 
Training  School  for  Nurses  at  the  Carney  Hospital,  South  Boston,  Mass.  Handsome 
octavo  volume  of  306  pages.      Cloth,  $1.50  net. 

"  It  contains  about  everything  that  a  nurse  ought  to  know  in  regard  to  drugs." — Journal  of  the 
American  Medical  Association. 

Grafstrom's  Mechano-therapy 

A  Text-Book  of  Mechano-therapy  (Massage  and  Medical  Gymnastics).  By 
Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  late  House  Physician.  City  Hospital,  Black- 
well's  Lsland,  N.  Y.      l2mo,  139  pages,  illustrated.     $1.00  net. 

"  Certainly  fulfills  its  mission  in  rendering  comprehensible  the  subjects  of  massage  and  medical 
gymnastics." — New   York  Medical  Journal. 


1 6  SAUNDERS'    BOOKS   ON  PRACTICE,  Etc. 

Jakob  and  Eshner's  Internal  Medicine  and  Diagnosis 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical  Diagnosis.  By  Dr. 
Chk.  Jakob,  of  Erlangen.  Edited,  with  additions,  by  A.  A.  Eshner,  M.  D.,  Pro- 
fessor of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  182  colored  figures  on 
68  plates,  64  text- illustrations,  259  pages  of  text.  Cloth,  ^^3.00  net.  In  Saunders' 
Hand-Atlas  Series. 

"  Can  be  recommended  unhesitatingly  to  the  practicing  physician  no  less  than  to  the  student." — 
Bulletin  0/  Johns  Hopkins  Hospital. 

Lockwood's   Practice   of   Medicine.  Revised  and  Enlarged 

A  Manual  of  the  Practice  of  Medicine.  By  Geo.  Roe  Lockwood,  M.  D., 
Attending  Physician  to  the  Bellevue  Hospital,  New  York  City.  Octavo,  S47  pages, 
with  79  illustrations  in  the  text  and  22  full-page  plates.      Cloth,  ^4.00  net. 

"  A  work  of  positive  merit,  and  one  which  we  gladly  welcome." — IVt'iv  York  Medical  Journal. 

Salinger  and  Kalteyer's  Modern  Medicine 

Modern  Medicine.  By  Julius  L.  Salinger,  M.  D.,  late  Demonstratoi  of  Clinical 
Medicine,  Jefferson  Medical  College;  and  F.  J.  Kalteyek,  M.  D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College.  Handsome  octavo,  801  pages,  illus- 
trated.    Cloth,  $4.00  net. 

"  I  have  carefully  examined  the  book,  and  find  it  to  be  thoroughly  trustworthy  in  all  respects  and  a 
valuable  text-book  for  the  medical  student." — Sam'l  O.  L.  Potter,  Formerly  Professor  of  Principles 
and  Practice  of  Medicine,  Cooper  Medical  College,  San  Francisco. 

Keating's  Life  Insurance 

How  to  Examine  for  Life  Insurance.  By  the  late  John  M.  Ke.\ting,  M.  D., 
Ex-President  of  the  Association  of  Life  Insurance  Medical  Directors.  Royal  octavo, 
211  pages.     With  numerous  illustrations.      Cloth,  $2.00  net. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination." — Medical 
News. 

Corwin's    Physical    Diagnosis.      Third  Edition,  Revised 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  A.  M.  Corwin,  A.  M., 
M.  D.,  Instructor  of  Physical  Diagnosis  in  Rush  Medical  College,  Chicago.  220 
pages,  illustrated.     Cloth,  flexible  covers,  $1.25  net. 

"  A  most  excellent  little  work.  It  arranges  orderly  and  in  sequence  the  various  objective  phenomena 
to  logical  solution  of  a  careful  diagnosis." — Journal  of  Nervous  and  Mental  Diseases. 

American  Text-Book  of  Theory  and  Practice 

American  Text-Book  of  the  Theory  and  Practice  of  Medicine.  Edited 
by  the  late  William  Pepper,  M.  D.,  LL.  D.,  Professor  of  the  Theory  and  Practice 
of  Medicine  and  of  Clinical  Medicine,  University  of  Penna.  Two  handsome  imperial 
octavos  of  about  1000  pages  each.  Illustrated.  Per  volume  :  Cloth,  ^5-00  net ;  Sheep 
or  Half  Morocco,  $6.00  net. 

■'  I  am  quite  sure  it  will  command  itself  both  to  practitioners  and  students  of  medicine,  and  become 
one  of  our  most  popular  text-books."—  Alfred  L>oomis,  M.  D.,  LL.  D.,  Professor  of  Pathology  and 
Practice  of  Medicine,  University  of  the    City  of  New   York. 

Stevens*  Practice  of   Medicine.      Sixth  Edition.  Revised— just  issued 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.  M.,  M.  D., 
Lecturer  on  Physical  Diagnosis,  University  of  Pennsylvania.  Specially  intended  for 
students  preparing  for  graduation  and  hospital  examinations.  Post-octavo,  519  pages  ; 
illustrated.     Flexible  leather,  $2.00  net. 

"An  excellent  condensation  of  the  essentials  of  medical  practice  for  the  student,  and  may  be  found 
also  an  excellent  reminder  for  the  busy  physician." — Buffalo  Medical  Journal. 


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